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FRED'S PHARMACY #1609
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
FRED'S PHARMACY #1609
Pharmacy Address
611 US HWY 65 SOUTH, SUITE A
DUMAS, AR 71639
Pharmacy Comments
Contract Details
Approval Date
4/19/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
ASHLEY GIBSON, ADMINISTRATOR
(870) 382-4303 Ext: 8234
Contract Pharmacy Representative
Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153
Signed By Date
4/19/2017
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