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WAL-MART PHARMACY 10-1061
SCH110071-00 Appling General Hospital
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Covered Entity Details
Entity Name
Appling General Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH110071-00
Entity Address
163 E Tollison Street
Baxley, GA 31513
Medicare Provider Number
110071
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1061
Pharmacy Address
136 EAST JARMAN ST.
HAZLEHURST, GA 31539
Pharmacy Comments
Contract Details
Approval Date
10/25/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/25/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ray Leadbetter, CEO
(912) 367-9841
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/25/2016
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