Contract Pharmacy Details

WAL-MART PHARMACY 10-1059
CAH251300-00 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH251300-00

Entity Address

330 N. BROAD ST.
FOREST, MS 39074

Medicare Provider Number

251300

Participating Start Date

1/1/2011

Last Recertification Date

8/29/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1059

Pharmacy Address

1309 HWY 35 SO
FOREST, MS 39074

Pharmacy Comments

Contract Details

Approval Date

4/16/2014

Contract Begin Date

7/1/2014

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Joseph S. McNulty III, President
(601) 849-6440

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

4/16/2014

340B Drug Pricing Program Database