Contract Pharmacy Details

WAL-MART PHARMACY 10-1367
DSH110104 CRISP REGIONAL HOSPITAL, INC.

Covered Entity Details

Entity Name

CRISP REGIONAL HOSPITAL, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110104

Entity Address

902 7TH STREET NORTH
CORDELE, GA 31015-5007

Medicare Provider Number

110104

Participating Start Date

1/1/2005

Last Recertification Date

9/9/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1367

Pharmacy Address

2720 WATSON BLVD
WARNER ROBINS, GA 31093

Pharmacy Comments

Contract Details

Approval Date

7/15/2021

Contract Begin Date

10/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/17/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jessica Carter, CFO
(229) 276-3130

Contract Pharmacy Representative

Walmart
Julie Howard, 340B Program Manager
(479) 277-1498

Signed By Date

7/15/2021

340B Drug Pricing Program Database