Contract Pharmacy Details

FRED'S PHARMACY #1536
DSH010099 D W MCMILLAN MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

D W MCMILLAN MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH010099

Entity Address

1301 BELLEVILLE AVENUE
BREWTON, AL 36427

Medicare Provider Number

010099

Participating Start Date

11/15/2022

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

FRED'S PHARMACY #1536

Pharmacy Address

802 FORREST AVE
EAST BREWTON, AL 36426

Pharmacy Comments

Contract Details

Approval Date

7/23/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/13/2018
Pharmacy closed

Contacts

Covered Entity Signing Official

Chris B. Griffin, Administrator
(251) 867-8061

Contract Pharmacy Representative

Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153

Signed By Date

7/23/2017

340B Drug Pricing Program Database