Contract Pharmacy Details

WAL-MART PHARMACY 10-5315
DSH110104 CRISP REGIONAL HOSPITAL, INC.

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

WAL-MART PHARMACY 10-5315

Pharmacy Address

2354 COMMERCE PARK DR.
ORLANDO, FL 32819

Pharmacy Comments

Contract Details

Approval Date

1/13/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Jessica Carter, CFO
(229) 276-3130

Contract Pharmacy Representative

Walmart
Julie Howard, 340B Program Manager
(479) 277-1498

Signed By Date

1/13/2020

340B Drug Pricing Program Database