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WAL-MART PHARMACY 10-1701
CAH111337-00 ELBERT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ELBERT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111337-00
Entity Address
4 MEDICAL DRIVE
ELBERTON, GA 30635
Medicare Provider Number
111337
Participating Start Date
10/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1701
Pharmacy Address
955 ELBERT STREET
ELBERTON, GA 30635
Pharmacy Comments
Contract Details
Approval Date
1/10/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JOHN T TAYLOR, CEO
(706) 213-2536
Contract Pharmacy Representative
Elbert Memorial Hospital
Jackie Harris, Director of Pharmacy
(706) 213-2548
Signed By Date
1/10/2024
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