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WAL-MART PHARMACY 10-1767
DSH340068 COLUMBUS REGIONAL HEALTHCARE SYSTEM
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Covered Entity Details
Entity Name
COLUMBUS REGIONAL HEALTHCARE SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340068
Entity Address
500 Jefferson Street
WHITEVILLE, NC 28472
Medicare Provider Number
340068
Participating Start Date
7/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1767
Pharmacy Address
4540 MAIN ST
SHALLOTTE, NC 28470
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marvin Jeffery Armstrong, CFO
(910) 642-1703
Contract Pharmacy Representative
Walmart Supercenter #1767
Athan S Vrettos, Pharm.D
(910) 754-2880
Signed By Date
1/15/2019
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