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MANIFEST PHARMACY, LLC
CAH451342-00 MITCHELL COUNTY HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
MITCHELL COUNTY HOSPITAL DISTRICT
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451342-00
Entity Address
997 WEST IH 20
COLORADO CITY, TX 79512
Medicare Provider Number
451342
Participating Start Date
7/1/2011
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
7/22/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
ROBBIE DEWBERRY, CHIEF EXECUTIVE OFFICER
(325) 728-3431 Ext: 7106
Contract Pharmacy Representative
Benjamin Walvoord, President
(864) 990-2880
Signed By Date
7/22/2014
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