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DIXON'S DISCOUNT PHARMACY
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
DIXON'S DISCOUNT PHARMACY
Pharmacy Address
434-B SOUTH CAPTAIN GLOSTER DRIVE
PO BOX 370
GLOSTER, MS 39638
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
1/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph S. McNulty III, President
(601) 849-6440
Contract Pharmacy Representative
Heather M. Priest, Pharmacist In Charge
(601) 225-7907
Signed By Date
7/14/2015
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