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CITY PHARMACY
CAH111325-00 WILLS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WILLS MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111325-00
Entity Address
120 GORDON STREET
WASHINGTON, GA 30673
Medicare Provider Number
111325
Participating Start Date
10/1/2014
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
CITY PHARMACY
Pharmacy Address
MUSSAD, HANI R.PH.
114 MAIN ST
PO BOX 368
LINCOLNTON, GA 30817-6300
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tracie P. Haughey, CEO
(706) 678-9212
Contract Pharmacy Representative
City Pharmacy
Heba L Kaldas, Owner
(706) 359-3618
Signed By Date
1/15/2020
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