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WAL-MART PHARMACY 10-0686
DSH110095 TIFT REGIONAL HEALTH SYSTEM, INC
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Covered Entity Details
Entity Name
TIFT REGIONAL HEALTH SYSTEM, INC
Subdivision Name
DBA TIFT REGIONAL MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH110095
Entity Address
901 E. 18TH ST.
TIFTON, GA 31794
Medicare Provider Number
110095
Participating Start Date
7/1/2004
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0686
Pharmacy Address
120 BENJAMIN H. HILL DR SW
FITZGERALD, GA 31750
Pharmacy Comments
Contract Details
Approval Date
4/12/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kimberly S Wills, Senior Vice President and CFO
(229) 353-3397
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/12/2022
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