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KELLEY DRUG AND SELECTIONS
CAH041326-00 DELTA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
DELTA MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH041326-00
Entity Address
811 HWY 65 SOUTH
DUMAS, AR 71639
Medicare Provider Number
041326
Participating Start Date
1/1/2011
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KELLEY DRUG AND SELECTIONS
Pharmacy Address
104 HOLLY STREET
P O BOX 21
MCGEHEE, AR 71654
Pharmacy Comments
Contract Details
Approval Date
1/16/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CRIS BOLIN, ADMINISTRATOR
(870) 382-4303 Ext: 8234
Contract Pharmacy Representative
KELLEY DRUG AND SELECTIONS
James Kelley, Owner/Pharmacist
(870) 222-5071
Signed By Date
1/16/2015
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