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Walmart Pharmacy 10-7611
DSH110132 MEMORIAL HOSPITAL AND MANOR
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AND MANOR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110132
Entity Address
1500 E SHOTWELL STREET
BAINBRIDGE, GA 39819
Medicare Provider Number
110132
Participating Start Date
10/1/2004
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James M Lambert, CEO
(229) 243-6105
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/9/2023
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