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WAL-MART PHARMACY 10-1192
DSH250124 MAGEE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MAGEE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250124
Entity Address
300 S.E. THIRD AVENUE
MAGEE, MS 39111
Medicare Provider Number
250124
Participating Start Date
4/1/2017
Last Recertification Date
Entity Termination Date
1/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1192
Pharmacy Address
1625 SIMPSON HIGHWAY #49
MAGEE, MS 39111
Pharmacy Comments
Contract Details
Approval Date
7/12/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Serina Blackwell, Chief Compliance Office
(601) 849-7323
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/12/2017
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