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WALNUT GROVE PLAZA PHARMACY #2
DSH250034 BAPTIST MEMORIAL HOSPITAL - NORTH MISSISSIPPI
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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
WALNUT GROVE PLAZA PHARMACY #2
Pharmacy Address
6027 WALNUT GROVE RD
STE 110
MEMPHIS, TN 38120-2115
Pharmacy Comments
Contract Details
Approval Date
2/10/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dana Williams, CFO
(662) 232-8102
Contract Pharmacy Representative
Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144
Signed By Date
2/10/2017
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