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FRED'S PHARMACY #2371
CH06273G MAINLINE HEALTH SYSTEMS INC
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Covered Entity Details
Entity Name
MAINLINE HEALTH SYSTEMS INC
Subdivision Name
Portland Elementary School Based Clinic
Type
HRSA-Funded Health Center
340B ID
CH06273G
Entity Address
314 Hwy 160 E
Portland, AR 71663
Grant Number
H80CS00638
Participating Start Date
7/1/2016
Last Recertification Date
2/12/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
FRED'S PHARMACY #2371
Pharmacy Address
406 HIGHWAY 425 SOUTH
MONTICELLO, AR 71655
Pharmacy Comments
Contract Details
Approval Date
1/14/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
GARY ALLAN NICHOLS, Executive Director
(870) 538-5414
Contract Pharmacy Representative
Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153
Signed By Date
1/14/2018
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