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LIBERTY PHARMACY INC
CAH441300-00 HICKMAN COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
HICKMAN COMMUNITY HOSPITAL
Subdivision Name
DBA SAINT THOMAS HICKMAN HOSPITAL
Type
Critical Access Hospital
340B ID
CAH441300-00
Entity Address
135 EAST SWAN STREET
CENTERVILLE, TN 37033
Medicare Provider Number
441300
Participating Start Date
1/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
LIBERTY PHARMACY INC
Pharmacy Address
1518 HWY 100
STE 100
CENTERVILLE, TN 37033
Pharmacy Comments
Contract Details
Approval Date
10/20/2011
Contract Begin Date
3/1/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
2/1/2011
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