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WALMART PHARMACY 10-5169
DSH110104 CRISP REGIONAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
CRISP REGIONAL HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110104
Entity Address
902 7TH STREET NORTH
CORDELE, GA 31015-5007
Medicare Provider Number
110104
Participating Start Date
1/1/2005
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/25/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jessica Carter, CFO
(229) 276-3130
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/25/2023
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