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WALMART PHARMACY 10-5169
DSH110135 R. J. Taylor Memorial Hospital
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Covered Entity Details
Entity Name
R. J. Taylor Memorial Hospital
Subdivision Name
DBA Taylor Regional Hospital
Type
Disproportionate Share Hospital
340B ID
DSH110135
Entity Address
222 Perry Highway
Hawkinsville, GA 31036
Medicare Provider Number
110135
Participating Start Date
3/15/2022
Last Recertification Date
9/7/2022
Entity Termination Date
10/1/2023
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
4/4/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jon Green, CEO
(205) 965-1950
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
4/4/2023
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