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WAL-MART PHARMACY 10-1011
CAH111306-00 EFFINGHAM HEALTH SYSTEM
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Covered Entity Details
Entity Name
EFFINGHAM HEALTH SYSTEM
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111306-00
Entity Address
459 HIGHWAY 119 SOUTH
SPRINGFIELD, GA 31329-3021
Medicare Provider Number
111306
Participating Start Date
1/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1011
Pharmacy Address
434 S COLUMBIA AVE
RINCON, GA 31326
Pharmacy Comments
Contract Details
Approval Date
12/21/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ED BROWN, CFO
(912) 754-0141
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/25/2012
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