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WAL-MART PHARMACY 10-1006
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
WAL-MART PHARMACY 10-1006
Pharmacy Address
1215 EAST 16TH AVENUE
CORDELE, GA 31015
Pharmacy Comments
Contract Details
Approval Date
7/13/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jessica Carter, CFO
(229) 276-3130
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/13/2015
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