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WAL-MART PHARMACY 10-1061
CAH111333-00 JEFF DAVIS
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Covered Entity Details
Entity Name
JEFF DAVIS
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111333-00
Entity Address
163 S TALLAHASSEE ST
HAZLEHURST, GA 31539
Medicare Provider Number
111333
Participating Start Date
10/1/2020
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1061
Pharmacy Address
136 EAST JARMAN ST.
HAZLEHURST, GA 31539
Pharmacy Comments
Contract Details
Approval Date
4/4/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/23/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tammy Mims, Chief Executive Officer
(912) 375-7781 Ext: 200
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/4/2017
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