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RIVER MEDICAL PHARMACY LLC
DSH110122 SOUTH GEORGIA MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTH GEORGIA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110122
Entity Address
2501 NORTH PATTERSON STREET
VALDOSTA, GA 31602
Medicare Provider Number
110122
Participating Start Date
7/1/2004
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
RIVER MEDICAL PHARMACY LLC
Pharmacy Address
4752 RESEARCH DR
SAN ANTONIO, TX 78240-5002
Pharmacy Comments
Contract Details
Approval Date
11/30/2022
Contract Begin Date
11/30/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ronald E Dean, CEO
(229) 259-4102
Contract Pharmacy Representative
SGMC
Scott Bruce Smith, Director of Pharmacy
(229) 259-4870
Signed By Date
11/30/2022
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