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WAL-MART PHARMACY 10-1069
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
WAL-MART PHARMACY 10-1069
Pharmacy Address
231 EASTSIDE DRIVE
NEWTON, MS 39345
Pharmacy Comments
Contract Details
Approval Date
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph S. McNulty III, President
(601) 849-6440
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/4/2016
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