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WAL-MART PHARMACY 10-5315
DSH110109 EMANUEL MEDICAL CENTER
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Covered Entity Details
Entity Name
EMANUEL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110109
Entity Address
117 KITE ROAD
SWAINSBORO, GA 30401
Medicare Provider Number
110109
Participating Start Date
10/1/2004
Last Recertification Date
9/7/2021
Entity Termination Date
12/14/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/3/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/14/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Damien Scott, CEO
(478) 289-1306
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/3/2020
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