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WILLACOOCHEE PHARMACY
CAH111305-00 Hospital Authority of Miller County DBA Miller County Hospital
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Covered Entity Details
Entity Name
Hospital Authority of Miller County DBA Miller County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111305-00
Entity Address
209 N. Cuthbert St
Colquitt, GA 39837
Medicare Provider Number
111305
Participating Start Date
10/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WILLACOOCHEE PHARMACY
Pharmacy Address
561 MAIN ST E
WILLACOOCHEE, GA 31650
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/18/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robin Rau, CEO
(229) 758-5954
Contract Pharmacy Representative
Willacoochee Pharmacy
Sammy Story, Pharmacy Owner
(912) 534-5195
Signed By Date
1/15/2020
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