Contract Pharmacy Details

HOLLIS DISCOUNT PHARMACY
CAH250010-00 TIPPAH COUNTY HOSPITAL

Covered Entity Details

Entity Name

TIPPAH COUNTY HOSPITAL

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH250010-00

Entity Address

1005 CITY AVE N
RIPLEY, MS 38663

Medicare Provider Number

250010

Participating Start Date

10/1/2015

Last Recertification Date

8/21/2018

Entity Termination Date

10/1/2019

Pharmacy Details

Pharmacy Name

HOLLIS DISCOUNT PHARMACY

Pharmacy Address

1008 CITY AVE N
RIPLEY, MS 38663-1413

Pharmacy Comments

Contract Details

Approval Date

1/14/2016

Contract Begin Date

4/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Bob Jones, Interim CEO
(662) 837-9221

Contract Pharmacy Representative

Marshall Hollis, Owner
(662) 837-7323

Signed By Date

1/14/2016