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DELTA DRUG OF DERMOTT INC
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
DELTA DRUG OF DERMOTT INC
Pharmacy Address
111 E PEDDICORD ST
DERMOTT, AR 71638
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
7/26/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
GARY ALLAN NICHOLS, Executive Director
(870) 538-5414
Contract Pharmacy Representative
Pharmacy
JEFF F. DUNN, OWNER/PHARMACIST
(870) 538-5510
Signed By Date
1/14/2018
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