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WAL-MART PHARMACY 10-0758
DSH110044 PHOEBE SUMTER MEDICAL CENTER
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Covered Entity Details
Entity Name
PHOEBE SUMTER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110044
Entity Address
126 Hwy 280 West
AMERICUS, GA 31719
Medicare Provider Number
110044
Participating Start Date
7/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0758
Pharmacy Address
1711 E LAMAR ST STE F
AMERICUS, GA 31709
Pharmacy Comments
Contract Details
Approval Date
7/21/2021
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
Brandi Lee Lunneborg, Chief Executive Officer
(229) 931-1191
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/21/2021
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