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SAMSON MERGER SUB, LLC
CAH111305-00 Hospital Authority of Miller County DBA Miller County Hospital
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Covered Entity Details
Entity Name
Hospital Authority of Miller County DBA Miller County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111305-00
Entity Address
209 N. Cuthbert St
Colquitt, GA 39837
Medicare Provider Number
111305
Participating Start Date
10/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
SAMSON MERGER SUB, LLC
Pharmacy Address
HARVEYS SUPERMARKET #1646
12246 COLUMBIA STREET
SUITE F
BLAKELY, GA 39823-2560
Pharmacy Comments
Contract Details
Approval Date
1/18/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/23/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Robin Rau, CEO
(229) 758-5954
Contract Pharmacy Representative
SE Grocers
Scott Wink, Director, Pharmacy Managed Care
(904) 370-7776
Signed By Date
1/18/2017
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