Contract Pharmacy Details

IHS PHARMACY
DSH110109 EMANUEL MEDICAL CENTER

Covered Entity Details

Entity Name

EMANUEL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110109

Entity Address

117 KITE ROAD
SWAINSBORO, GA 30401

Medicare Provider Number

110109

Participating Start Date

10/1/2004

Last Recertification Date

9/7/2021

Entity Termination Date

12/14/2021

Pharmacy Details

Pharmacy Name

IHS PHARMACY

Pharmacy Address

150 S LEROY ST
METTER, GA 30439-4631

Pharmacy Comments

Contract Details

Approval Date

10/16/2017

Contract Begin Date

1/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Damien Scott, CEO
(478) 289-1306

Contract Pharmacy Representative

IHS Pharmacy
Dean Stone, Owner
(912) 685-2803

Signed By Date

10/16/2017