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WAL-MART PHARMACY 10-0686
DSH110073 DORMINY MEDICAL CENTER
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Covered Entity Details
Entity Name
DORMINY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110073
Entity Address
200 PERRY HOUSE ROAD
FITZGERALD, GA 31750
Medicare Provider Number
110073
Participating Start Date
9/9/2005
Last Recertification Date
9/7/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0686
Pharmacy Address
120 BENJAMIN H. HILL DR SW
FITZGERALD, GA 31750
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paige Wynn, COO / CFO
(229) 468-3845
Contract Pharmacy Representative
Dorminy Medical Center
ARTHUR HILL, PHARMACY DIRECTOR
(229) 424-7235
Signed By Date
7/17/2018
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