Contract Pharmacy Details

SAMSON MERGER SUB, LLC
DSH110104 CRISP REGIONAL HOSPITAL, INC.

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

SAMSON MERGER SUB, LLC

Pharmacy Address

HARVEYS SUPERMARKET #1627
1011 E. 16TH AVENUE
CORDELE, GA 31015-1539

Pharmacy Comments

Contract Details

Approval Date

4/4/2017

Contract Begin Date

7/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/21/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jessica Carter, CFO
(229) 276-3130

Contract Pharmacy Representative

SE Grocers
Scott Wink, Director, Pharmacy Managed Care
(904) 370-7776

Signed By Date

4/4/2017

340B Drug Pricing Program Database