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WAL-MART PHARMACY 10-1174
DSH010091 GROVE HILL MEMORIAL HOSPITAL
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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
WAL-MART PHARMACY 10-1174
Pharmacy Address
34301 HIGHWAY 43
THOMASVILLE, AL 36784
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
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2020
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