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PROFESSIONAL APOTHECARY
DSH010101 CITIZENS BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
CITIZENS BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010101
Entity Address
604 STONE AVENUE
TALLADEGA, AL 35161
Medicare Provider Number
010101
Participating Start Date
1/1/2016
Last Recertification Date
Entity Termination Date
1/1/2016
Pharmacy Details
Pharmacy Name
PROFESSIONAL APOTHECARY
Pharmacy Address
210 NORTH STREET WEST
TALLADEGA, AL 35160
Pharmacy Comments
Contract Details
Approval Date
1/7/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/10/2015
Contacts
Covered Entity Signing Official
Zach Abercrombie, CFO
(256) 761-4509
Contract Pharmacy Representative
Signed By Date
1/7/2014
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