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MCRAES PHARMACY OF DOUGLAS INC
DSH110089 COFFEE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COFFEE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110089
Entity Address
1101 OCILLA ROAD
DOUGLAS, GA 31533
Medicare Provider Number
110089
Participating Start Date
4/1/2007
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
MCRAES PHARMACY OF DOUGLAS INC
Pharmacy Address
1002 WARD ST W
DOUGLAS, GA 31533-2251
Pharmacy Comments
Contract Details
Approval Date
4/17/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lavonda Cravey, VP Corporate Revenue
(912) 383-5600
Contract Pharmacy Representative
McRae's Pharmacy of Douglas, Inc.
Andrew Holt, Pharmacist/Owner
(912) 384-5255
Signed By Date
4/17/2018
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