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WALMART PHARMACY 10-5169
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
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jimmy LaDon Toole, CEO
(229) 403-9175
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/13/2023
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