Contract Pharmacy Details

CITY DRUG
DSH010091 GROVE HILL MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

GROVE HILL MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH010091

Entity Address

295 SOUTH JACKSON STREET
GROVE HILL, AL 36451

Medicare Provider Number

010091

Participating Start Date

1/1/2020

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

CITY DRUG

Pharmacy Address

123 JACKSON ST
PO BOX 790
GROVE HILL, AL 36451

Pharmacy Comments

Contract Details

Approval Date

1/14/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Kenneth Larrimore, COO
(251) 275-3191

Contract Pharmacy Representative

City Drugs
Brooks Davis, Owner
(251) 275-3669

Signed By Date

1/14/2020