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MISSISSIPPI CVS PHARMACY, L.L.C.
DSH250141 BAPTIST MEMORIAL HOSPITAL- DESOTO
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Covered Entity Details
Entity Name
BAPTIST MEMORIAL HOSPITAL- DESOTO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250141
Entity Address
7601 SOUTHCREST PARKWAY
SOUTHAVEN, MS 38671-4739
Medicare Provider Number
250141
Participating Start Date
9/5/2008
Last Recertification Date
9/15/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08994
2955 CHURCH RD E
SOUTHAVEN, MS 38671
Pharmacy Comments
Contract Details
Approval Date
7/11/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Huffman, CEO and Administrator
(662) 772-2118
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
7/11/2013
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