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WAL-MART PHARMACY 10-5315
DSH110135 R. J. Taylor Memorial Hospital
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Covered Entity Details
Entity Name
R. J. Taylor Memorial Hospital
Subdivision Name
DBA Taylor Regional Hospital
Type
Disproportionate Share Hospital
340B ID
DSH110135
Entity Address
222 Perry Highway
Hawkinsville, GA 31036
Medicare Provider Number
110135
Participating Start Date
3/15/2022
Last Recertification Date
9/7/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/6/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon Green, CEO
(205) 965-1950
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/13/2020
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