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WAL-MART PHARMACY 10-5363
DSH110165 Prime Healthcare Foundation - SOUTHERN REGIONAL, LLC dba Southern Regional Medical Center
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Covered Entity Details
Entity Name
Prime Healthcare Foundation - SOUTHERN REGIONAL, LLC dba Southern Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110165
Entity Address
11 UPPER RIVERDALE ROAD SW
RIVERDALE, GA 30274-2600
Medicare Provider Number
110165
Participating Start Date
10/1/2003
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5363
Pharmacy Address
11465 TARA BLVD
LOVEJOY, GA 30250
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
3/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charlotte W Dupre, President and CEO
(770) 991-8160
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2020
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