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WAL-MART PHARMACY 10-1658
DSH110028 UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110028
Entity Address
1350 WALTON WAY
AUGUSTA, GA 30901
Medicare Provider Number
110028
Participating Start Date
7/1/2002
Last Recertification Date
8/29/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1658
Pharmacy Address
2205 HARRISON RD
THOMSON, GA 30824
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/14/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James R. Davis, President and CEO
(706) 774-8061 Ext: 7064966908
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/14/2014
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