Contract Pharmacy Details

FRED'S PHARMACY
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

FRED'S PHARMACY

Pharmacy Address

237 WOODLAND DR
FOREST, MS 39074-3529

Pharmacy Comments

Contract Details

Approval Date

10/16/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2019
Pharmacy closed

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

Shannon Strickland, SVP, Pharmacy Development
(901) 238-3113

Signed By Date

10/16/2014

340B Drug Pricing Program Database