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MISSISSIPPI CVS PHARMACY, L.L.C.
CAH251300-00 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL
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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
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05846
822 HWY 35 N
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
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
4/16/2014
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