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PIONEER FAMILY PHARMACY ABERDEEN
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
PIONEER FAMILY PHARMACY ABERDEEN
Pharmacy Address
502 JACKSON STREET
ABERDEEN, MS 39730
Pharmacy Comments
Contract Details
Approval Date
7/14/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Joseph S. McNulty III, President
(601) 849-6440
Contract Pharmacy Representative
Jerry Fortenberry, Pharmacist
(662) 369-4249
Signed By Date
7/14/2015
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