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WAL-MART PHARMACY 10-1458
CH044790 PRIMARY HEALTH CARE CENTER OF DADE, INC.
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Covered Entity Details
Entity Name
PRIMARY HEALTH CARE CENTER OF DADE, INC.
Subdivision Name
PRIMARY HEALTH CARE CENTER TRENTON
Type
HRSA-Funded Health Center
340B ID
CH044790
Entity Address
13570 N Main St
Trenton, GA 30752-2012
Grant Number
H80CS00649
Participating Start Date
1/1/1998
Last Recertification Date
3/5/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1458
Pharmacy Address
3040 BATTLEFIELD PKWY
FORT OGLETHORPE, GA 30742
Pharmacy Comments
Contract Details
Approval Date
1/14/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/12/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
DIANA U. ALLEN, CEO
(706) 657-7575 Ext: 217
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/14/2014
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