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WAL-MART PHARMACY #10-5797
DSH110007 PHOEBE PUTNEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PHOEBE PUTNEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110007
Entity Address
417 WEST THIRD AVENUE
ALBANY, GA 31701
Medicare Provider Number
110007
Participating Start Date
10/1/2003
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY #10-5797
Pharmacy Address
262 CORDELE ROAD
ALBANY, GA 31705
Pharmacy Comments
Contract Details
Approval Date
7/16/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/13/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brian Church, CFO & CAO
(229) 312-4066
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/16/2021
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