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WAL-MART PHARMACY 10-5315
SCH250057-00 KINGS DAUGHTERS MEDICAL CENTER
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Covered Entity Details
Entity Name
KINGS DAUGHTERS MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH250057-00
Entity Address
427 HWY 51 N
BROOKHAVEN, MS 39601
Medicare Provider Number
250057
Participating Start Date
1/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/5/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/4/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
RANDY PIRTLE, CFO
(601) 835-9271
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/5/2017
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