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SOUTHCOAST MEDICAL GROUP, LLC
DSH110024 CANDLER HOSPITAL
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Covered Entity Details
Entity Name
CANDLER HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110024
Entity Address
5353 REYNOLDS STREET
SAVANNAH, GA 31405
Medicare Provider Number
110024
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SOUTHCOAST MEDICAL GROUP, LLC
Pharmacy Address
SOUTHCOAST PHARMACY
1326 EISENHOWER DRIVE
BUILDING 1
SAVANNAH, GA 31406
Pharmacy Comments
Contract Details
Approval Date
12/6/2012
Contract Begin Date
12/6/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/4/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PAUL P. HINCHEY, CEO
(912) 819-6901
Contract Pharmacy Representative
John Leffler, Director of Pharmacy
(912) 681-3528
Signed By Date
10/11/2012
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