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MCRAE'S PHARMACY OF DOUGLAS
DSH110089 COFFEE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COFFEE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110089
Entity Address
1101 OCILLA ROAD
DOUGLAS, GA 31533
Medicare Provider Number
110089
Participating Start Date
4/1/2007
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
MCRAE'S PHARMACY OF DOUGLAS
Pharmacy Address
INC.
1002 WEST WARD STREET
P.O. BOX 1089
DOUGLAS, GA 31533
Pharmacy Comments
Contract Details
Approval Date
11/25/2011
Contract Begin Date
11/28/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peggy Kirkland, Director of Pharmacy
(912) 383-5609
Contract Pharmacy Representative
Hampton Wade, Owner
(912) 384-5292
Signed By Date
11/21/2011
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