Contract Pharmacy Details

PUBLIX PHARMACY #0526
DSH110034 AU Medical Center, Inc.

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 #0526

Pharmacy Address

4274 WASHINGTON ROAD
EVANS, GA 30809

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

340B Drug Pricing Program Database