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WAL-MART PHARMACY 10-0756
CH04479K Primary Health Care Center Of Dade, Inc.
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Covered Entity Details
Entity Name
Primary Health Care Center Of Dade, Inc.
Subdivision Name
Primary Health Care Center Rome
Type
HRSA-Funded Health Center
340B ID
CH04479K
Entity Address
1400 Crane St SW
Rome, GA 30161-6333
Grant Number
H80CS00649
Participating Start Date
10/1/2022
Last Recertification Date
2/1/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0756
Pharmacy Address
13427 HIGHWAY 27
TRION, GA 30753
Pharmacy Comments
Contract Details
Approval Date
1/16/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DIANA U. ALLEN, CEO
(706) 620-4494 Ext: 8549
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/16/2024
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