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WAL-MART PHARMACY 10-5315
DSH110092 DODGE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
DODGE COUNTY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110092
Entity Address
901 GRIFFIN AVE
EASTMAN, GA 31023
Medicare Provider Number
110092
Participating Start Date
7/1/2006
Last Recertification Date
8/31/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/8/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jimmy LaDon Toole, CEO
(229) 403-9175
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/8/2019
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