Contract Pharmacy Details

ADVANCED PHARMACY, LLC
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

ADVANCED PHARMACY, LLC

Pharmacy Address

ADVANCED PHARMACY
350 FEASTER ROAD
SUITE D
GREENVILLE, SC 29615-6176

Pharmacy Comments

Contract Details

Approval Date

4/18/2016

Contract Begin Date

7/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/5/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

Gregory P. Santulli, President
(770) 339-1190 Ext: 7063

Signed By Date

4/18/2016

340B Drug Pricing Program Database