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UNADILLA DRUG CO
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
UNADILLA DRUG CO
Pharmacy Address
413 2ND ST
P O BOX 14
UNADILLA, GA 31091
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jon Green, CEO
(205) 965-1950
Contract Pharmacy Representative
Unadilla Drug Co
Dhara Patel, owner
(229) 944-5298
Signed By Date
10/15/2020
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