Covered Entity Details

CH047430 GEORGIA HIGHLANDS MEDICAL SERVICES, INC. (Active) - information as of 6/28/2025 12:26:03 AM

Main Details

Name

GEORGIA HIGHLANDS MEDICAL SERVICES, INC.

Subdivision Name

GHMS Cumming Family Health Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-001646

340B ID

CH047430

Grant Number

H80CS00470

Additional Details

Current Program Status

Active

Registration Date

1/1/2005

Participating Start Date

1/1/2005

Participating Approval Date

4/5/2005

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

Georgia Highlands Medical Services
Todd Shifflet, CEO
(770) 887-1668 Ext: 1102

Primary Contact

Georgia Highlands Medical Services, Inc
Jessica Pulliam, Pharmacist
(770) 887-1670

Addresses

Street Address

260 Elm St
Cumming, GA 30040-2467

Billing Address

Georgia Highlands Medical Services, INC.
475 Tribble Gap Road
Cumming, GA 30040

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
GA	000192574C,003146289A,003183795A,003188430A,003168146A,000192574E,003245090A,003290096A	1053702191,1063419422,1124565650,1174529192,1407281058,1407306418,1811501455,1194987412,1427762707

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/07/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/07/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/07/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/07/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/07/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/07/2024	01/01/2025		01/01/2025
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	10/07/2024	01/01/2025		01/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/12/2019	07/01/2019	09/04/2022	09/06/2022
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/07/2024	01/01/2025		01/01/2025
Contract Detail	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	01/13/2014	04/01/2014	02/13/2023	02/14/2023
Contract Detail	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	01/13/2014	04/01/2014	02/13/2023	02/14/2023
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/01/2021	01/01/2022		01/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/01/2021	01/01/2022		01/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/07/2024	01/01/2025		01/01/2025
Contract Detail	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	04/12/2019	07/01/2019	09/04/2022	09/06/2022
Contract Detail	ECKERD CORPORATION	RITE AID #11739	954 JOE FRANK HARRIS PKWY	CARTERSVILLE	GA	30120	07/14/2017	10/01/2017	11/06/2017	11/06/2017
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/07/2024	01/01/2025		01/01/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/07/2024	01/01/2025		01/01/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/07/2024	01/01/2025		01/01/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/07/2024	01/01/2025		01/01/2025
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05352	4110 PLEASANT HILL RD.	DULUTH	GA	30096	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05995	7395 SPOUT SPRINGS RD.	FLOWERY BRANCH	GA	30542	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05640	6327 HWY. 53 EAST	DAWSONVILLE	GA	30534	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02236	1600 TOWNE LAKE PKWY	WOODSTOCK	GA	30189	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 16561	3205 WOODWARD CROSSING BLVD SUITE B	BUFORD	GA	30519	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05692	13 NORTH TENNESSEE ST.	CARTERSVILLE	GA	30120	10/01/2021	01/01/2022	05/25/2023	05/25/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00191	5510 CASTLEBERRY ROAD	CUMMING	GA	30040	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07273	129 MARIETTA HIGHWAY	CANTON	GA	30114	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02539	5740 ATLANTA HIGHWAY	ALPHARETTA	GA	30004	10/01/2021	01/01/2022	03/28/2023	04/10/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04682	4895 POST RD.	CUMMING	GA	30040	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07736	601 HOWARD SIMMONS RD.	EAST ELLIJAY	GA	30540	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03392	266 EAST CHURCH ST	JASPER	GA	30143	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03086	1162 WEST AVE.	CARTERSVILLE	GA	30120	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05355	603 CANTON HWY.	CUMMING	GA	30040	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17450	5865 SPOUT SPRINGS RD	FLOWERY BRANCH	GA	30542	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00279	2605 HAMILTON MILL RD	BUFORD	GA	30519	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07888	6120 HICKORY FLAT HWY.	CANTON	GA	30115	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08976	965 JOE FRANK HARRIS PKWY SE	CARTERSVILLE	GA	30120	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17527	2022 CUMMING HWY	CANTON	GA	30115	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05653	1950 BUFORD HWY.	BUFORD	GA	30518	10/01/2021	01/01/2022		01/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04113	3095 OLD ATLANTA RD.	CUMMING	GA	30041	04/13/2022	07/01/2022		07/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05071	3709 THOMPSON BRIDGE RD.	GAINESVILLE	GA	30506	04/13/2022	07/01/2022		07/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02945	13933 ALPHARETTA HWY.	MILTON	GA	30004	04/10/2023	07/01/2023		07/01/2023
Contract Detail	GOODSON DRUG CO	116 MAPLE ST		CUMMING	GA	30040	04/05/2005	04/05/2005	03/18/2016	03/18/2016
Contract Detail	KROGER DRUGSTORE #473	2655 FREEDOM PARKWAY		CUMMING	GA	30041	07/14/2017	10/01/2017	11/01/2018	11/01/2018
Contract Detail	KROGER PHARMACY #629	125 MAIN STREET MARKET PLACE SE		CARTERSVILLE	GA	30121	07/14/2017	10/01/2017	11/01/2018	11/01/2018
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/07/2024	01/01/2025		01/01/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/07/2024	01/01/2025		01/01/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/07/2024	01/01/2025		01/01/2025
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/12/2019	07/01/2019	09/04/2022	09/06/2022
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/12/2019	07/01/2019	09/04/2022	09/06/2022
Contract Detail	SOUTHSIDE INFUSION	7700 MAIN ST STE 210		HOUSTON	TX	77030-4457	01/15/2020	04/01/2020	03/28/2022	06/02/2022
Contract Detail	SOUTHSIDE MASTER LLC	DBA SOUTHSIDE PHARMACY	755 MOUNT VERNON HWY NE STE 450	ATLANTA	GA	30328-4292	01/15/2020	04/01/2020	03/28/2022	06/02/2022
Contract Detail	SOUTHSIDE PHARMACY 3	6330 WEST LOOP S STE 700C		BELLAIRE	TX	77401-2928	01/15/2020	04/01/2020	03/28/2022	06/02/2022
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01556	1170 EMMET ST N	CHARLOTTESVILLE	VA	22903	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07561	503 MAIN ST.	LOUISA	VA	23093	10/01/2021	01/01/2022	02/09/2023	02/14/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/15/2019	07/01/2019	04/24/2019	04/24/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/03/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-0615	101 MARKET PLACE BLVD		CARTERSVILLE	GA	30121	10/14/2024	01/01/2025		01/01/2025
Contract Detail	WAL-MART PHARMACY 10-0878	1500 MARKET PLACE BLVD.		CUMMING	GA	30041	04/15/2019	07/01/2019	04/24/2019	04/24/2019
Contract Detail	WAL-MART PHARMACY 10-0878	1500 MARKET PLACE BLVD.		CUMMING	GA	30041	07/03/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-3874	98 POWER CENTER DR		DAWSONVILLE	GA	30534	04/15/2019	07/01/2019	04/24/2019	04/24/2019
Contract Detail	WAL-MART PHARMACY 10-3874	98 POWER CENTER DR		DAWSONVILLE	GA	30534	07/03/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/15/2019	07/01/2019	04/24/2019	04/24/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/03/2019	10/01/2019		10/01/2019
Contract Detail	WALGREEN CO	DBA: WALGREENS #09981	101 PROMINENCE POINT PKWY	CANTON	GA	30114-9009	04/10/2013	07/01/2013		04/10/2013
Contract Detail	WALGREEN CO	DBA: WALGREENS #09494	4397 SUDDERTH ROAD	SUGAR HILL	GA	30518	01/11/2017	04/01/2017		01/11/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07340	120 MARIETTA HIGHWAY	CANTON	GA	30114-2303	04/10/2013	07/01/2013		04/10/2013
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10423	3290 KEITH BRIDGE RD.	CUMMING	GA	30041-3937	04/10/2013	07/01/2013		04/10/2013
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15180	101 N TENNESSEE ST	CARTERSVILLE	GA	30120	04/10/2014	07/01/2014		04/10/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07946	1650 BUFORD HWY	CUMMING	GA	30041	04/14/2014	07/01/2014		04/14/2014
Contract Detail	WALGREEN CO.	RITE AID #11737	2017 MARIETTA HWY	CANTON	GA	30114	04/12/2019	07/01/2019	07/16/2019	07/16/2019
Contract Detail	WALGREEN CO.	WALGREENS #17686	954 JOE FRANK HARRIS PKWY SE	CARTERSVILLE	GA	30120	05/13/2020	06/08/2020		06/08/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/03/2022	01/01/2023	07/29/2024	07/31/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/03/2022	01/01/2023	07/29/2024	07/31/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/03/2022	01/01/2023	07/29/2024	07/31/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/10/2023	07/01/2023		07/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/04/2023	01/01/2024		01/01/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH047430	Active	BPS-H80-001646	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	GHMS Cumming Family Health Center	260 Elm St	Cumming	GA
CH04743B	Active	BPS-H80-003944	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	GHMS Canton Family Health Center	220 OAKSIDE LN BLDG	CANTON	GA
CH04743C	Active	BPS-H80-012842	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	GHMS Bartow Family Health Center	775 West Ave Ste A	Cartersville	GA
CH04743D	Active	BPS-H80-017102	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	Highlands Medical Plaza	475 Tribble Gap Rd	Cumming	GA
CH04743E	Active	BPS-H80-019133	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	GHMS Dawsonville Family Health Center	5959 Highway 53 E Ste 100	Dawsonville	GA
CH04743F	Active	BPS-H80-031232	GEORGIA HIGHLANDS MEDICAL SERVICE INC	GHMS Canton Center	210 Oakside Ln	Canton	GA
CH04743G	Active	BPS-H80-035763	GEORGIA HIGHLANDS MEDICAL SERVICE INC	GHMS Cumming Elementary Center	540 Dahlonega Street	Cumming	GA
CH04743H	Active	BPS-H80-036783	GEORGIA HIGHLANDS MEDICAL SERVICE INC	GHMS Buford Family Health Center	3919 Carter Road STE B	Buford	GA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH047430	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/01/2025
CH047430	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/01/2025
CH047430	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/01/2025
CH047430	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/01/2025
CH047430	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2025
CH047430	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/01/2025
CH047430	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/01/2025
CH047430	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	07/01/2019	09/04/2022
CH047430	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2025
CH047430	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2025
CH047430	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2025
CH047430	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2025
CH047430	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2025
CH047430	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2025
CH047430	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2025
CH047430	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2025
CH047430	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2025
CH047430	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2025
CH047430	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	04/01/2014	02/13/2023
CH047430	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	04/01/2014	02/13/2023
CH047430	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/01/2022
CH047430	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/01/2022
CH047430	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2025
CH047430	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	07/01/2019	09/04/2022
CH047430	ECKERD CORPORATION	RITE AID #11739	954 JOE FRANK HARRIS PKWY	CARTERSVILLE	GA	30120	10/01/2017	11/06/2017
CH047430	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/01/2025
CH047430	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/01/2025
CH047430	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/01/2025
CH047430	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/01/2025
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05352	4110 PLEASANT HILL RD.	DULUTH	GA	30096	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05995	7395 SPOUT SPRINGS RD.	FLOWERY BRANCH	GA	30542	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05640	6327 HWY. 53 EAST	DAWSONVILLE	GA	30534	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02236	1600 TOWNE LAKE PKWY	WOODSTOCK	GA	30189	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 16561	3205 WOODWARD CROSSING BLVD SUITE B	BUFORD	GA	30519	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05692	13 NORTH TENNESSEE ST.	CARTERSVILLE	GA	30120	01/01/2022	05/25/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00191	5510 CASTLEBERRY ROAD	CUMMING	GA	30040	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07273	129 MARIETTA HIGHWAY	CANTON	GA	30114	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02539	5740 ATLANTA HIGHWAY	ALPHARETTA	GA	30004	01/01/2022	03/28/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04682	4895 POST RD.	CUMMING	GA	30040	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07736	601 HOWARD SIMMONS RD.	EAST ELLIJAY	GA	30540	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03392	266 EAST CHURCH ST	JASPER	GA	30143	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03086	1162 WEST AVE.	CARTERSVILLE	GA	30120	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05355	603 CANTON HWY.	CUMMING	GA	30040	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17450	5865 SPOUT SPRINGS RD	FLOWERY BRANCH	GA	30542	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00279	2605 HAMILTON MILL RD	BUFORD	GA	30519	01/01/2022	02/09/2023
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07888	6120 HICKORY FLAT HWY.	CANTON	GA	30115	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08976	965 JOE FRANK HARRIS PKWY SE	CARTERSVILLE	GA	30120	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17527	2022 CUMMING HWY	CANTON	GA	30115	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05653	1950 BUFORD HWY.	BUFORD	GA	30518	01/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04113	3095 OLD ATLANTA RD.	CUMMING	GA	30041	07/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05071	3709 THOMPSON BRIDGE RD.	GAINESVILLE	GA	30506	07/01/2022
CH047430	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02945	13933 ALPHARETTA HWY.	MILTON	GA	30004	07/01/2023
CH04743B	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08976	965 JOE FRANK HARRIS PKWY SE	CARTERSVILLE	GA	30120	07/01/2024
CH04743E	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05640	6327 HWY. 53 EAST	DAWSONVILLE	GA	30534	07/01/2024
CH04743C	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03086	1162 WEST AVE.	CARTERSVILLE	GA	30120	07/01/2024
CH04743D	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05355	603 CANTON HWY.	CUMMING	GA	30040	07/01/2024
CH04743F	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07273	129 MARIETTA HIGHWAY	CANTON	GA	30114	07/01/2024
CH04743H	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00191	5510 CASTLEBERRY ROAD	CUMMING	GA	30040	07/01/2024
CH04743G	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04682	4895 POST RD.	CUMMING	GA	30040	07/01/2024
CH047430	GOODSON DRUG CO	116 MAPLE ST		CUMMING	GA	30040	04/05/2005	03/18/2016
CH047430	KROGER DRUGSTORE #473	2655 FREEDOM PARKWAY		CUMMING	GA	30041	10/01/2017	11/01/2018
CH047430	KROGER PHARMACY #629	125 MAIN STREET MARKET PLACE SE		CARTERSVILLE	GA	30121	10/01/2017	11/01/2018
CH047430	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2025
CH047430	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2025
CH047430	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2025
CH047430	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	07/01/2019	09/04/2022
CH047430	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	07/01/2019	09/04/2022
CH047430	SOUTHSIDE INFUSION	7700 MAIN ST STE 210		HOUSTON	TX	77030-4457	04/01/2020	03/28/2022
CH047430	SOUTHSIDE MASTER LLC	DBA SOUTHSIDE PHARMACY	755 MOUNT VERNON HWY NE STE 450	ATLANTA	GA	30328-4292	04/01/2020	03/28/2022
CH047430	SOUTHSIDE PHARMACY 3	6330 WEST LOOP S STE 700C		BELLAIRE	TX	77401-2928	04/01/2020	03/28/2022
CH047430	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01556	1170 EMMET ST N	CHARLOTTESVILLE	VA	22903	01/01/2022	02/09/2023
CH047430	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07561	503 MAIN ST.	LOUISA	VA	23093	01/01/2022	02/09/2023
CH047430	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2019	04/24/2019
CH047430	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2019
CH047430	WAL-MART PHARMACY 10-0615	101 MARKET PLACE BLVD		CARTERSVILLE	GA	30121	01/01/2025
CH047430	WAL-MART PHARMACY 10-0878	1500 MARKET PLACE BLVD.		CUMMING	GA	30041	07/01/2019	04/24/2019
CH047430	WAL-MART PHARMACY 10-0878	1500 MARKET PLACE BLVD.		CUMMING	GA	30041	10/01/2019
CH047430	WAL-MART PHARMACY 10-3874	98 POWER CENTER DR		DAWSONVILLE	GA	30534	07/01/2019	04/24/2019
CH047430	WAL-MART PHARMACY 10-3874	98 POWER CENTER DR		DAWSONVILLE	GA	30534	10/01/2019
CH047430	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2019	04/24/2019
CH047430	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2019
CH047430	WALGREEN CO	DBA: WALGREENS #09981	101 PROMINENCE POINT PKWY	CANTON	GA	30114-9009	07/01/2013
CH047430	WALGREEN CO	DBA: WALGREENS #09494	4397 SUDDERTH ROAD	SUGAR HILL	GA	30518	04/01/2017
CH047430	WALGREEN CO.	DBA: WALGREENS # 07340	120 MARIETTA HIGHWAY	CANTON	GA	30114-2303	07/01/2013
CH047430	WALGREEN CO.	DBA: WALGREENS #10423	3290 KEITH BRIDGE RD.	CUMMING	GA	30041-3937	07/01/2013
CH047430	WALGREEN CO.	DBA: WALGREENS #15180	101 N TENNESSEE ST	CARTERSVILLE	GA	30120	07/01/2014
CH047430	WALGREEN CO.	DBA: WALGREENS # 07946	1650 BUFORD HWY	CUMMING	GA	30041	07/01/2014
CH047430	WALGREEN CO.	RITE AID #11737	2017 MARIETTA HWY	CANTON	GA	30114	07/01/2019	07/16/2019
CH047430	WALGREEN CO.	WALGREENS #17686	954 JOE FRANK HARRIS PKWY SE	CARTERSVILLE	GA	30120	06/08/2020
CH047430	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/01/2023	07/29/2024
CH047430	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/01/2023	07/29/2024
CH047430	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/01/2023	07/29/2024
CH047430	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH047430	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/12/2025 10:51 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003290096A	2/12/2025 10:51 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	2/12/2025 10:51 AM
Details	Last Recertification Date	Update	Recertification	1/31/2024 4:35:18 PM	2/12/2025 10:51:53 AM	2/12/2025 10:51 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1194987412	1/31/2024 4:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	1/31/2024 4:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1427762707	1/31/2024 4:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	1/31/2024 4:35 PM
Details	Last Recertification Date	Update	Recertification	1/31/2023 9:49:39 AM	1/31/2024 4:35:18 PM	1/31/2024 4:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	1/31/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003245090A	1/31/2023 9:49 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	1/31/2023 9:49 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1811501455	1/31/2023 9:49 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	1/31/2023 9:49 AM
Details	Last Recertification Date	Update	Recertification	2/2/2022 10:21:53 AM	1/31/2023 9:49:39 AM	1/31/2023 9:49 AM
Details	Last Recertification Date	Update	Recertification	2/1/2021 4:11:12 PM	2/2/2022 10:21:53 AM	2/2/2022 10:21 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1174529192 ( )		2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1063419422 ( )		2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1407281058 ( )		2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1407306418 ( )		2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1124565650 ( )		2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1053702191 ( )		2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053702191	2/1/2021 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1063419422	2/1/2021 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124565650	2/1/2021 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174529192	2/1/2021 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1407281058	2/1/2021 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	2/1/2021 4:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1407306418	2/1/2021 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	2/1/2021 4:11 PM
Details	Last Recertification Date	Update	Recertification	1/30/2020 8:08:15 AM	2/1/2021 4:11:12 PM	2/1/2021 4:11 PM
Contacts	Primary Contact	Update	Change Request	Mistry, Cheryl Pharmacy Director Georgia Highlands Medical Services,inc. 4702971013	Pulliam, Jessica Pharmacist Georgia Highlands Medical Services, Inc 7708871670	12/7/2020 12:10 PM
Contacts	Primary Contact	Update	New Registration	Mistry, Cheryl Pharmacy Director Georgia Highlands Medical Services,inc. 4702971013	Mistry, Cheryl Pharmacy Director Georgia Highlands Medical Services,inc. 4702971013	10/5/2020 1:28 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000172574E (GA)		1/30/2020 8:08 AM
Details	Last Recertification Date	Update	Recertification	2/1/2019 9:50:01 AM	1/30/2020 8:08:15 AM	1/30/2020 8:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/16/2019 9:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000192574E	12/16/2019 9:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	12/16/2019 9:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000192574C	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000172574E	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003146289A	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003183795A	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003188430A	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003168146A	3/5/2019 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/5/2019 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174529192	3/5/2019 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1063419422	3/5/2019 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1407281058	3/5/2019 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1407306418	3/5/2019 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1124565650	3/5/2019 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053702191	3/5/2019 3:33 PM
Details	Last Recertification Date	Update	Recertification	2/12/2018 9:35:02 AM	2/1/2019 9:50:01 AM	2/1/2019 9:50 AM
Addresses	Billing Address	Insert	Recertification		Georgia Highlands Medical Services, INC. 475 Tribble Gap Road Cumming, GA 30040	2/12/2018 9:35 AM
Details	Last Recertification Date	Update	Recertification	2/9/2017 12:00:00 AM	2/12/2018 9:35:02 AM	2/12/2018 9:35 AM
Details	Entity Subname	Update	Recertification	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	GHMS Cumming Family Health Center	2/12/2018 9:35 AM
Details	Entity Name	Update	Change Request	GEORGIA HIGHLANDS MEDICAL SERVICE INC	GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	11/29/2017 1:01 PM
Contacts	Authorizing Official	Update		Shifflet, Todd CEO 7708871668-1102	Shifflet, Todd CEO Georgia Highlands Medical Services 7708871668-1102	11/2/2017 8:49 AM
Contacts	Primary Contact	Update		Mistry, Cheryl Pharmacy Director 4702971013	Mistry, Cheryl Pharmacy Director Georgia Highlands Medical Services,inc. 4702971013	10/2/2017 10:40 AM
Contacts	Authorizing Official	Insert			Shifflet, Todd CEO 7708871668-1102	7/14/2017 12:35 PM
Contacts	Primary Contact	Update		Davenport, Sean Pharmacy Services Program Manager 7708871670	Mistry, Cheryl Pharmacy Director 4702971013	5/26/2017 10:33 AM
Addresses	Main Address	Insert			260 Elm St Cumming, GA 30040-2467	2/9/2017 3:42 PM
Details	Last Recertification Date	Update		2/24/2016 12:00:00 AM	2/9/2017 12:00:00 AM	2/9/2017 3:42 PM
Contacts	Primary Contact	Insert			Davenport, Sean Pharmacy Services Program Manager 7708871670	2/24/2016 10:39 AM
Details	Last Recertification Date	Update		3/2/2015 12:00:00 AM	2/24/2016 12:00:00 AM	2/24/2016 10:39 AM
Details	Last Recertification Date	Update		2/11/2014 12:00:00 AM	3/2/2015 12:00:00 AM	3/2/2015 10:16 AM
Details	Entity Name	Update		GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	GEORGIA HIGHLANDS MEDICAL SERVICE INC	3/31/2014 4:25 PM
Details	Entity Subname	Update			GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	3/31/2014 4:25 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	2/11/2014 12:00:00 AM	2/11/2014 9:24 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/28/2013 9:41 AM
Details	Last Recertification Date	Insert				11/7/2006 6:03 AM
Details	Grant Number	Insert			H80CS00470	11/7/2006 6:03 AM
Details	340B ID	Insert			CH047430	11/7/2006 6:03 AM
Details	Is Authorizing Official EHB Data	Insert				11/7/2006 6:03 AM
Dates	Last Date That 340B Drugs Purchased	Insert				11/7/2006 6:03 AM
Details	Medicare Provider Number	Insert				11/7/2006 6:03 AM
Details	Entity Name	Insert			GEORGIA HIGHLANDS MEDICAL SERVICES, INC.	11/7/2006 6:03 AM
Details	Program Code	Insert			CH	11/7/2006 6:03 AM
Details	Entity Subname	Insert				11/7/2006 6:03 AM
Dates	Participating Approval Date	Insert			4/5/2005 12:00:00 AM	11/7/2006 6:03 AM
Details	State	Insert			Active	11/7/2006 6:03 AM
Dates	Registration Date	Insert			1/1/2005 12:00:00 AM	11/7/2006 6:03 AM
Dates	Signed By Date	Insert				11/7/2006 6:03 AM
Dates	Start Date	Insert			1/1/2005 12:00:00 AM	11/7/2006 6:03 AM
Terminations	Termination Comments	Insert				11/7/2006 6:03 AM
Terminations	Termination Date	Insert				11/7/2006 6:03 AM
Terminations	Termination Effective Date	Insert				11/7/2006 6:03 AM
Terminations	Termination Reason	Insert				11/7/2006 6:03 AM

340B Drug Pricing Program Database