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WAL-MART PHARMACY 10-0593
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
WAL-MART PHARMACY 10-0593
Pharmacy Address
1450 S.E. BOWENS MILL RD
DOUGLAS, GA 31533
Pharmacy Comments
Contract Details
Approval Date
10/24/2012
Contract Begin Date
10/24/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DONALD C. LEWIS Jr., CFO
(912) 383-5620
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/3/2012
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