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PUBLIX PHARMACY
DSH110034 AU Medical Center, Inc.
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Covered Entity Details
Entity Name
AU Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110034
Entity Address
1120 15TH ST.
AUGUSTA, GA 30912
Medicare Provider Number
110034
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY
Pharmacy Address
PUBLIX PHARMACY #0486
334 EAST MARTINTOWN RD
NORTH AUGUSTA, SC 29841
Pharmacy Comments
Contract Details
Approval Date
10/19/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/20/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Allen R Butcher, CFO
(706) 721-3929
Contract Pharmacy Representative
Publix
Amin Mrugesh, 340B Program Manager
(863) 688-1188 Ext: 52388
Signed By Date
10/19/2021
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