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WAL-MART PHARMACY 10-0862
CAH111335-00 LIBERTY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LIBERTY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111335-00
Entity Address
462 E.G. MILES PARKWAY
HINESVILLE, GA 31313
Medicare Provider Number
111335
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0862
Pharmacy Address
751 WEST OGLETHORPE HWY.
HINESVILLE, GA 31313
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/20/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Donna Cochrane, CNO
(912) 369-9441
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2018
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