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WAL-MART PHARMACY 10-1018
DSH110092 DODGE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
DODGE COUNTY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110092
Entity Address
901 GRIFFIN AVE
EASTMAN, GA 31023
Medicare Provider Number
110092
Participating Start Date
7/1/2006
Last Recertification Date
8/31/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1018
Pharmacy Address
1099 INDIAN DR.
EASTMAN, GA 31023
Pharmacy Comments
Contract Details
Approval Date
9/21/2012
Contract Begin Date
9/21/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
KEVIN Lynn BIERSCHENK, CFO
(478) 448-4067
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/5/2012
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