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EAST ALABAMA APOTHECARY STORE 4
DSH010029 EAST ALABAMA MEDICAL CENTER
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Covered Entity Details
Entity Name
EAST ALABAMA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010029
Entity Address
2000 PEPPERELL PARKWAY
OPELIKA, AL 36801-5422
Medicare Provider Number
010029
Participating Start Date
10/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
EAST ALABAMA APOTHECARY STORE 4
Pharmacy Address
900 CAMP AUBURN RD STE P101
AUBURN, AL 36832
Pharmacy Comments
Contract Details
Approval Date
4/6/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SAM PRICE, CFO
(334) 528-1313
Contract Pharmacy Representative
East Alabama Apothecary, LLC
Kim Witt, Pharmacy Manager
(334) 528-2293
Signed By Date
4/6/2021
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