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WINN-DIXIE PHARMACY #533
CAH251335-00 Kemper CAH, Inc d/b/a John C. Stennis Memorial Hospital
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Covered Entity Details
Entity Name
Kemper CAH, Inc d/b/a John C. Stennis Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251335-00
Entity Address
14365 Hwy 16 West
DeKalb, MS 39328
Medicare Provider Number
251335
Participating Start Date
10/1/2012
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WINN-DIXIE PHARMACY #533
Pharmacy Address
5100 HIGHWAY 39 N.
MERIDIAN, MS 39301
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Justin Palmer, Administrator
(769) 486-1038
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
4/16/2018
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