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WALGREEN 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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11793
1100 BALL STREET
PERRY, GA 31069
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/12/2021
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