Contract Pharmacy Details

ASHLAND DRUG STORE INC
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

ASHLAND DRUG STORE INC

Pharmacy Address

15917 BOUNDARY DR
ASHLAND, MS 38603

Pharmacy Comments

Contract Details

Approval Date

7/7/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Patrick Chapman, CEO
(662) 837-9221

Contract Pharmacy Representative

ashland
Larry Melton, Owner
(662) 224-8922

Signed By Date

7/7/2017