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MARBLE CITY PHARMACY INC.
DSH010164 COOSA VALLEY MEDICAL CENTER
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Covered Entity Details
Entity Name
COOSA VALLEY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010164
Entity Address
315 W. HICKORY STREET
SYLACAUGA, AL 35150
Medicare Provider Number
010164
Participating Start Date
12/1/2005
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
MARBLE CITY PHARMACY INC.
Pharmacy Address
264 W FORT WILLIAMS ST
SYLACAUGA, AL 35150
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/15/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Roland L Thacker, CFO
(256) 401-4534
Contract Pharmacy Representative
Marble City Pharmacy
Jacob Johnson, Pharmacist/President
(256) 245-4446
Signed By Date
1/14/2019
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