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WALGREEN CO.
DSH110104 CRISP REGIONAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
CRISP REGIONAL HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110104
Entity Address
902 7TH STREET NORTH
CORDELE, GA 31015-5007
Medicare Provider Number
110104
Participating Start Date
1/1/2005
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #19839
650 E WASHINGTON AVE
ASHBURN, GA 31714
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jessica Carter, CFO
(229) 276-3130
Contract Pharmacy Representative
CRISP REGIONAL HOSPITAL, INC.
Whitney Hill Brown, Director of Pharmacy
(229) 276-3386
Signed By Date
4/12/2019
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