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WAL-MART PHARMACY 10-1076
DSH110107 Atrium Health Navicent The Medical Center
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Covered Entity Details
Entity Name
Atrium Health Navicent The Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110107
Entity Address
777 HEMLOCK ST.
MACON, GA 31201-2102
Medicare Provider Number
110107
Participating Start Date
12/1/1992
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1076
Pharmacy Address
1401 GRAY HIGHWAY
MACON (NE), GA 31211
Pharmacy Comments
Contract Details
Approval Date
2/27/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/4/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rhonda Perry, CFO
(478) 633-1440
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/31/2013
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