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ROCHELLE DRUG COMPANY
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
ROCHELLE DRUG COMPANY
Pharmacy Address
600 SECOND AVENUE
ROCHELLE, GA 31079
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
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
Michael Miller, Owner & Pharmacist
(229) 365-7447
Signed By Date
7/15/2013
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