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WAL-MART PHARMACY 10-1143
SCH110100-00 JEFFERSON HOSPITAL
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Covered Entity Details
Entity Name
JEFFERSON HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH110100-00
Entity Address
1067 PEACHTREE STREET
LOUISVILLE, GA 30434-1558
Medicare Provider Number
110100
Participating Start Date
7/1/2019
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1143
Pharmacy Address
1308 SOUTH HARRIS STREET
SANDERSVILLE, GA 31082
Pharmacy Comments
Contract Details
Approval Date
2/28/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
Michael J. Sombar Jr., CFO
(478) 625-7000 Ext: 205
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/28/2013
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