Contract Pharmacy Details

WALGREEN CO
DSH110135 R. J. Taylor Memorial Hospital

Covered Entity Details

Entity Name

R. J. Taylor Memorial Hospital

Subdivision Name

DBA Taylor Regional Hospital

Type

Disproportionate Share Hospital

340B ID

DSH110135

Entity Address

222 Perry Highway
Hawkinsville, GA 31036

Medicare Provider Number

110135

Participating Start Date

3/15/2022

Last Recertification Date

9/7/2022

Entity Termination Date

10/1/2023

Pharmacy Details

Pharmacy Name

WALGREEN CO

Pharmacy Address

DBA: WALGREENS #10884
1081 GA HIGHWAY 96
WARNER ROBINS, GA 31088

Pharmacy Comments

Contract Details

Approval Date

6/13/2012

Contract Begin Date

6/13/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/31/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Dan S. Maddock, CEO
(478) 783-0200

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

5/21/2012

340B Drug Pricing Program Database