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WAL-MART PHARMACY 10-5422
CAH111305-00 Hospital Authority of Miller County DBA Miller County Hospital
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Covered Entity Details
Entity Name
Hospital Authority of Miller County DBA Miller County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111305-00
Entity Address
209 N. Cuthbert St
Colquitt, GA 39837
Medicare Provider Number
111305
Participating Start Date
10/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5422
Pharmacy Address
500 EAST ALICE STREET
BAINBRIDGE, GA 39819
Pharmacy Comments
Contract Details
Approval Date
4/2/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robin Rau, CEO
(229) 758-5954
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/2/2018
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