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ADAMS DRUG STORE INC
DSH110104 CRISP REGIONAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
CRISP REGIONAL HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110104
Entity Address
902 7TH STREET NORTH
CORDELE, GA 31015-5007
Medicare Provider Number
110104
Participating Start Date
1/1/2005
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
ADAMS DRUG STORE INC
Pharmacy Address
408 E 16TH AVE STE B
CORDELE, GA 31015-1699
Pharmacy Comments
Contract Details
Approval Date
4/19/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/17/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jessica Carter, CFO
(229) 276-3130
Contract Pharmacy Representative
Russell Adams, Owner
(229) 273-3433
Signed By Date
4/19/2013
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