Contract Pharmacy Details

MISSISSIPPI CVS PHARMACY, L.L.C.
DSH250034 BAPTIST MEMORIAL HOSPITAL - NORTH MISSISSIPPI

Covered Entity Details

Entity Name

BAPTIST MEMORIAL HOSPITAL - NORTH MISSISSIPPI

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH250034

Entity Address

1100 Belk Blvd
OXFORD, MS 38655-5373

Medicare Provider Number

250034

Participating Start Date

7/1/2018

Last Recertification Date

9/8/2020

Entity Termination Date

6/4/2021

Pharmacy Details

Pharmacy Name

MISSISSIPPI CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04376
1209 SUNSET DR.
GRENADA, MS 38901

Pharmacy Comments

Contract Details

Approval Date

7/15/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/5/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Dana Williams, CFO
(662) 232-8102

Contract Pharmacy Representative

CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298

Signed By Date

7/15/2013

340B Drug Pricing Program Database