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NICHOLLS PHARMACY LLC
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
NICHOLLS PHARMACY LLC
Pharmacy Address
1003 VAN STREAT HWY
P.O. BOX 247
NICHOLLS, GA 31554-5031
Pharmacy Comments
Contract Details
Approval Date
7/10/2014
Contract Begin Date
10/1/2014
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
Nicholls Pharmacy LLC
Jan Scott, Owner
(912) 345-1021
Signed By Date
7/10/2014
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