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PALACE DRUG OF SALEM
CAH041322-00 FULTON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
FULTON COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH041322-00
Entity Address
679 N MAIN ST
SALEM, AR 72576-0517
Medicare Provider Number
041322
Participating Start Date
9/24/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
PALACE DRUG OF SALEM
Pharmacy Address
PALACE DRUG OF SALEM LLC
106 HIGHWAY 62 W
SALEM, AR 72576
Pharmacy Comments
Contract Details
Approval Date
10/3/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Charles Willett, CEO/ADMINISTRATOR
(870) 895-6096
Contract Pharmacy Representative
Larry Burns, Member
(870) 895-3811
Signed By Date
10/3/2014
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