Contract Pharmacy Details

FRED'S PHARMACY # 1639
DSH010112 Whitfield Regional Hospital

Covered Entity Details

Entity Name

Whitfield Regional Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH010112

Entity Address

105 US HIGHWAY 80 EAST
DEMOPOLIS, AL 36732

Medicare Provider Number

010112

Participating Start Date

4/1/2005

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

FRED'S PHARMACY # 1639

Pharmacy Address

505 US HWY 80 WEST STE. A
DEMOPOLIS, AL 36732

Pharmacy Comments

Contract Details

Approval Date

10/17/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/20/2019
Pharmacy closed

Contacts

Covered Entity Signing Official

ARTHUR D. EVANS, CEO/ADMINISTRATOR
(334) 287-2502

Contract Pharmacy Representative

Fred's Pharmacy
Betty Ngo, Sr. Director 340B Program Operations
(901) 481-0346

Signed By Date

10/17/2016

340B Drug Pricing Program Database