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ROBERTS PHARMACY INC
DSH110194 DONALSONVILLE HOSPITAL
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Covered Entity Details
Entity Name
DONALSONVILLE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110194
Entity Address
102 HOSPITAL CIRCLE
DONALSONVILLE, GA 39845
Medicare Provider Number
110194
Participating Start Date
7/1/2013
Last Recertification Date
9/8/2016
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
ROBERTS PHARMACY INC
Pharmacy Address
803 N WILEY AVE
P.O. BOX 157
DONALSONVILLE, GA 39845
Pharmacy Comments
Contract Details
Approval Date
7/8/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Contacts
Covered Entity Signing Official
Chuck Orrick, Administrator
(229) 524-5217 Ext: 213
Contract Pharmacy Representative
Roberts Pharmacy
Jack Mills, Owner
(229) 524-2349
Signed By Date
7/8/2013
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