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FRED'S PHARMACY #1221
CAH251315-00 Baptist Medical Center - Leake, Inc.
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Covered Entity Details
Entity Name
Baptist Medical Center - Leake, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251315-00
Entity Address
1100 Hwy 16 East
CARTHAGE, MS 39051
Medicare Provider Number
251315
Participating Start Date
1/1/2014
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
FRED'S PHARMACY #1221
Pharmacy Address
300 S PEARL ST
CARTHAGE, MS 39051-4108
Pharmacy Comments
Contract Details
Approval Date
10/10/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/3/2018
Ownership change
Contacts
Covered Entity Signing Official
Daryl W. Weaver, CEO
(601) 267-1422
Contract Pharmacy Representative
Gary Beckham, Pharmacist in Charge
(601) 267-3293
Signed By Date
10/10/2016
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