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FREDS PHARMACY #2111
CAH251336-00 Baptist Medical Center Attala
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Covered Entity Details
Entity Name
Baptist Medical Center Attala
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251336-00
Entity Address
220 Hwy 12 W
Kosciusko, MS 39090
Medicare Provider Number
251336
Participating Start Date
4/1/2014
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
FREDS PHARMACY #2111
Pharmacy Address
340 HIGHWAY 12 W
KOSCIUSKO, MS 39090-3209
Pharmacy Comments
Contract Details
Approval Date
10/4/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
John Dawson, CEO
(662) 290-3300
Contract Pharmacy Representative
Fred's Pharmacy
Betty Ngo, Sr. Director 340B Program Operations
(901) 481-0346
Signed By Date
10/4/2016
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