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WAL-MART PHARMACY 10-1061
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 10-1061
Pharmacy Address
136 EAST JARMAN ST.
HAZLEHURST, GA 31539
Pharmacy Comments
Contract Details
Approval Date
10/24/2012
Contract Begin Date
10/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/2/2018
Business decision by covered entity and/or pharmacy
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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