Contract Pharmacy Details

FREDS PHARMACY #2431
CAH251300-00 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH251300-00

Entity Address

330 N. BROAD ST.
FOREST, MS 39074

Medicare Provider Number

251300

Participating Start Date

1/1/2011

Last Recertification Date

8/29/2024

Pharmacy Details

Pharmacy Name

FREDS PHARMACY #2431

Pharmacy Address

304 NORTHSIDE DR
NEWTON, MS 39345-2378

Pharmacy Comments

Contract Details

Approval Date

1/15/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/2/2020
Pharmacy closed

Contacts

Covered Entity Signing Official

Sydney Sawyer, CEO
(601) 469-4151 Ext: 301

Contract Pharmacy Representative

Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153

Signed By Date

1/15/2018

340B Drug Pricing Program Database