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WAL-MART PHARMACY 10-1658
DSH110034 AU Medical Center, Inc.
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Covered Entity Details
Entity Name
AU Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110034
Entity Address
1120 15TH ST.
AUGUSTA, GA 30912
Medicare Provider Number
110034
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1658
Pharmacy Address
2205 HARRISON RD
THOMSON, GA 30824
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
Timothy M. Gaillard, Chief Operating Officer
(706) 721-7228
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2020
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