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DELIVERCARERX PHARMACY LLC
CAH250010-00 TIPPAH COUNTY HOSPITAL
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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
DELIVERCARERX PHARMACY LLC
Pharmacy Address
DELIVERCARERX PHARMACY LLC
1471 E BUSINESS CENTER DR
STE 200
MT PROSPECT, IL 60056
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
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
Agape
Dave Krishna, CEO
(847) 965-1600
Signed By Date
10/16/2017
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