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RICHMOND HILL PHARMACY, INC.
DSH110036 MEMORIAL HEALTH UNIVERSITY MED CENTER
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Covered Entity Details
Entity Name
MEMORIAL HEALTH UNIVERSITY MED CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110036
Entity Address
4700 WATERS AVENUE
SAVANNAH, GA 31404
Medicare Provider Number
110036
Participating Start Date
1/1/2004
Last Recertification Date
11/29/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
RICHMOND HILL PHARMACY, INC.
Pharmacy Address
ATTN: ALEX S. TUCKER
2409 HIGHWAY 17
P.O. BOX 1060
RICHMOND HILL, GA 31324
Pharmacy Comments
Contract Details
Approval Date
4/5/2011
Contract Begin Date
5/1/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
3/29/2011
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