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WAL-MART PHARMACY 10-2630
SCH110124-00 Wayne Memorial Hospital
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Covered Entity Details
Entity Name
Wayne Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH110124-00
Entity Address
865 South First Street
Jesup, GA 31545
Medicare Provider Number
110124
Participating Start Date
1/1/2012
Last Recertification Date
8/19/2019
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2630
Pharmacy Address
1100 NORTH FIRST ST
JESUP, GA 31545
Pharmacy Comments
Contract Details
Approval Date
9/5/2012
Contract Begin Date
9/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/19/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gregory A. Jones, CFO
(912) 530-3305
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/29/2012
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