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WAL-MART PHARMACY 10-1072
DSH110104 CRISP REGIONAL HOSPITAL, INC.
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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 10-1072
Pharmacy Address
1830 US HIGHWAY 82 W
TIFTON, GA 31793
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
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