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FRED'S PHARMACY
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
FRED'S PHARMACY
Pharmacy Address
156 EIGHTH ST
HELENA, GA 31037-3846
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/24/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
KEVIN Lynn BIERSCHENK, CFO
(478) 448-4067
Contract Pharmacy Representative
Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153
Signed By Date
4/17/2017
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