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WINN-DIXIE #456
DSH010065 RUSSELL MEDICAL CENTER
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Covered Entity Details
Entity Name
RUSSELL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010065
Entity Address
3316 Highway 280
ALEXANDER CITY, AL 35010
Medicare Provider Number
010065
Participating Start Date
1/1/2008
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
WINN-DIXIE #456
Pharmacy Address
1061 U. S. 280 E.
ALEXANDER CITY, AL 35010
Pharmacy Comments
Contract Details
Approval Date
1/22/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
L.E. Peace III, CEO
(256) 329-7188
Contract Pharmacy Representative
Ron Richmond, Group Director of Managed
(847) 916-4592
Signed By Date
1/22/2016
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