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EAST ALABAMA APOTHECARY STORE 3
DSH010099 D W MCMILLAN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
D W MCMILLAN MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010099
Entity Address
1301 BELLEVILLE AVENUE
BREWTON, AL 36427
Medicare Provider Number
010099
Participating Start Date
11/15/2022
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
EAST ALABAMA APOTHECARY STORE 3
Pharmacy Address
1171 GATEWOOD DR STE 1200
AUBURN, AL 36830
Pharmacy Comments
Contract Details
Approval Date
11/16/2022
Contract Begin Date
11/16/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stacy Hines, Administrator
(251) 809-8429
Contract Pharmacy Representative
EAMC
Trey Bankson, 340B contact
(334) 528-3950
Signed By Date
11/16/2022
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