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MANIFEST PHARMACY, LLC
CAH451324-00 LILLIAN M. HUDSPETH MEMORIAL HOSP.
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Covered Entity Details
Entity Name
LILLIAN M. HUDSPETH MEMORIAL HOSP.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451324-00
Entity Address
308 HUDSPETH AVE.
SONORA, TX 76950
Medicare Provider Number
451324
Participating Start Date
7/1/2019
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
MANIFEST PHARMACY, LLC
Pharmacy Address
1018 S BATESVILLE RD
STE 4A
GREER, SC 29650-5203
Pharmacy Comments
Contract Details
Approval Date
4/7/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/14/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ROBERT A. PASCASIO, CEO
(325) 387-2521
Contract Pharmacy Representative
Benjamin Walvoord, President
(864) 990-2880
Signed By Date
4/7/2014
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