Covered Entity Details

DSH110078 EMORY UNIVERSITY HOSPITAL MIDTOWN (Active) - information as of 6/26/2025 3:02:08 AM

Main Details

Name

EMORY UNIVERSITY HOSPITAL MIDTOWN

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110078

Medicare Provider Number

110078

Additional Details

Current Program Status

Active

Registration Date

3/1/2006

Participating Start Date

4/1/2006

Participating Approval Date

3/1/2006

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Emory Decatur, Emory Hillandale
Lisa Urbistondo, Vice President & CFO
(404) 501-5025

Primary Contact

Emory Healthcare
Sydney Kchao, Corporate Director of Pharmacy, Business Operations and Finance
(404) 686-2147

Addresses

Street Address

550 PEACHTREE STREET, NE
ATLANTA, GA 30308-2209

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
7/31/09 UPDATED ENTITY NAME (WAS EMORY CRAWFORD LONG HOSPITAL) 6/24/10 ADDED SHIP TO ADDRESS	06/24/2010
7/31/09 UPDATED ENTITY NAME (WAS EMORY CRAWFORD LONG HOSPITAL) 6/24/10 ADDED SHIP TO ADDRESS	03/01/2006

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	003241260A,003283804A,003166275A,099009370A,000000503A	1033582531,1073837167,1144203563,1427669670,1528767506

Shipping Addresses

Shipping Address 1

Emory University Hospital Midtown
550 Peachtree St NE
Atlanta, GA 30308

Shipping Address 2

Safecor
317 New Boston St., Suite 100
Woburn, MA 01801-4226

Shipping Address 3

The Pharmacy at Emory Midtown
550 Peachtree St. NE
Room L103A
Atlanta, GA 30308

Shipping Address 4

The Pharmacy at Emory
1750 Gambrell Drive
Suite T203
Atlanta, GA 30322

Shipping Address 5

Emory Specialty Pharmacy
550 Peachtree St NE
Suite 1760
Atlanta, GA 30308

Shipping Address 6

Non-Oncology Infusion Pharmacy at Building A
1365A Clifton Road NE, 3rd Floor, Bldg A
A3446
Atlanta, GA 30322

Shipping Address 7

Winship at Emory Midtown Home Health Pharmacy
550 Peachtree Street NE
STE 06.5P30
Atlanta, GA 30308

Shipping Address 8

Winship at Emory Midtown Hospital Pharmacy
550 Peachtree Street NE
STE 06.5P30
Atlanta, GA 30308

Shipping Address 9

The Pharmacy at Winship Emory Midtown
550 Peachtree Street NE
STE OL5P10
Atlanta, GA 30308

Shipping Address 10

Winship at Emory Midtown - Receiving
575 West Peachtree Street
Atlanta
GA, GA 30308

Shipping Address 11

Safecor Health
4060 Business Park Drive
Columbus, OH 43204

Shipping Address 12

Emory Pharmacy Access Solutions
550 Peachtree Street NE
STE OL5P10
Atlanta, GA 30308

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	01/12/2015	04/01/2015		05/03/2017
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	01/12/2015	04/01/2015	08/01/2017	09/02/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/12/2015	04/01/2015	12/31/2021	01/06/2022
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/11/2017	07/01/2017		05/03/2017
Contract Detail	ACCREDO HEALTH GROUP INC	190 TECHNOLOGY PKWY STE 120		NORCROSS	GA	30092-2914	10/15/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/15/2024	01/01/2025		01/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/12/2015	04/01/2015	05/31/2023	06/21/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/12/2015	04/01/2015		05/03/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.		PHARMACY 2 BOULDEN CIRCLE SUITE 1	NEW CASTLE	DE	19720	01/12/2015	04/01/2015	07/07/2015	05/03/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/12/2015	10/01/2015		05/03/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/06/2022	04/01/2022		04/01/2022
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/17/2015	10/01/2015	12/30/2020	01/04/2021
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/05/2018	04/01/2018	12/30/2020	01/04/2021
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	CORAM CVS/SPECIALTY INFUSION SERVICES	2140 NEWMARKET PARKWAY SUITE 106	MARIETTA	GA	30067-8767	07/06/2017	10/01/2017	12/30/2020	01/04/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/14/2021	10/01/2021	04/14/2022	09/02/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04513	2830 N. DRUID HILLS RD. NE	ATLANTA	GA	30329	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04592	12-J BROAD ST., SW	ATLANTA	GA	30303	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04717	2429 MARTIN LUTHER KING JR. DR.	ATLANTA	GA	30311	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04718	11625 JONES BRIDGE RD.	ALPHARETTA	GA	30022	04/23/2015	07/01/2015	11/04/2015	05/03/2017
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04720	1554 N DECATUR RD NE	ATLANTA	GA	30307	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04747	1544 PIEDMONT AVE NE	ATLANTA	GA	30324	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05395	2237 CASCADE ROAD SW	ATLANTA	GA	30311	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05621	3030 HEADLAND DR.	ATLANTA	GA	30311	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07336	520 BOULEVARD SE	ATLANTA	GA	30312	04/23/2015	07/01/2015	03/20/2020	04/05/2020
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04178	895 RALPH ABERNATHY BLVD., SW	ATLANTA	GA	30310	04/23/2015	07/01/2015	07/29/2015	05/03/2017
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04178	895 RALPH ABERNATHY BLVD., SW	ATLANTA	GA	30310	01/04/2016	04/01/2016	03/20/2020	04/05/2020
Contract Detail	KROGER DRUG STORE #475	4915 FLAT SHOALS PKWY		DECATUR	GA	30034	07/16/2014	10/01/2014	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #298	1700 MONROE DR NE		ATLANTA	GA	30324-5033	07/16/2014	10/01/2014	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #318	2205 LAVISTA ROAD		ATLANTA	GA	30329	07/16/2014	10/01/2014	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #346	1715 HOWELL MILL RD NW		ATLANTA	GA	30318-3167	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #350	4920 ROSWELL ROAD		ATLANTA	GA	30342	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #427	101 FAIRVIEW ROAD		ELLENWOOD	GA	30294	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #459	2875 NORTH DECATUR ROAD		DECATUR	GA	30033	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE #491	3871 PEACHTREE ROAD NE		ATLANTA	GA	30319-3388	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	KROGER DRUGSTORE 467	227 SANDY SPRINGS PLACE		SANDY SPRINGS	GA	30328	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	OPTUM INFUSION SERVICES 209, INC.	425 FRANKLIN GATEWAY	SUITE 535	MARIETTA	GA	30067-7736	01/06/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	01/06/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	7167 E. KEMPER RD.		CINCINNATI	OH	45249	01/06/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM INFUSION SERVICES 553, LLC	6531 MERIDIEN DR	SUITE 113	RALEIGH	NC	27616	01/06/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/14/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/14/2022	04/15/2022		04/21/2022
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	01/06/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/14/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/06/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	07/14/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/14/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/15/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/14/2021	10/01/2021		10/01/2021
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/06/2025	04/01/2025		04/01/2025
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/12/2017	10/01/2017	10/01/2022	10/17/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/26/2015	04/01/2015	12/30/2020	01/04/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2686	560 AMSTERDAM AVE, STE #E	ATLANTA	GA	30306	07/17/2017	10/01/2017	03/20/2020	04/05/2020
Contract Detail	PUBLIX PHARMACY #0282	2900 PEACHTREE ROAD NW		ATLANTA	GA	30305	07/16/2015	10/01/2015	08/24/2021	08/24/2021
Contract Detail	PUBLIX PHARMACY #0723	2155 N DECATUR RD		DECATUR	GA	30033	07/16/2015	10/01/2015	08/24/2021	08/24/2021
Contract Detail	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0783	2235 GLENWOOD AVENUE SE	ATLANTA	GA	30316	07/16/2015	10/01/2015	05/15/2020	09/24/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3213	1950 SAND LAKE ROAD #5	ORLANDO	FL	32809	07/16/2015	10/01/2015	02/08/2016	05/03/2017
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX CENTRAL PHARMACY #3201	2424 ORLANDO CENTRAL PARKWAY	ORLANDO	FL	32809	01/04/2016	04/01/2016	08/24/2021	08/24/2021
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	01/15/2025	04/01/2025		04/01/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	01/15/2025	04/01/2025		04/01/2025
Contract Detail	THE KROGER DRUG STORE #212	3959A LAVISTA ROAD		TUCKER	GA	30084	10/29/2014	01/01/2015	10/15/2019	10/20/2019
Contract Detail	WAL-MART PHARMACY 10-0787	7050 HIGHWAY 85		RIVERDALE	GA	30274	07/16/2014	10/01/2014	12/15/2019	12/15/2019
Contract Detail	WAL-MART PHARMACY 10-3401	6149 OLD NATIONAL HIGHWAY		COLLEGE PARK	GA	30349	07/16/2014	10/01/2014	12/15/2019	12/15/2019
Contract Detail	WAL-MART PHARMACY 10-3709	2427 GRESHAM ROAD SE		ATLANTA(GRESHAM)	GA	30316	07/16/2014	10/01/2014	12/15/2019	12/15/2019
Contract Detail	WALGREEN CO	DBA: WALGREENS # 05759	585 DEKALB INDUSTRIAL WAY	DECATUR	GA	30033	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #10265	4535 ROSWELL RD	ATLANTA	GA	30342	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #10457	5201 LAVISTA RD	TUCKER	GA	30084	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO	WALGREENS SPECIALTY PHARMACY #15131	631 PROFESSIONAL DRIVE STE 100	LAWRENCEVILLE	GA	30046	10/19/2016	01/01/2017	09/07/2017	01/05/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02359	5373 PEACHTREE INDUSTRIAL BLVD	CHAMBLEE	GA	30341-2139	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05336	5320 MEMORIAL DR	STONE MOUNTAIN	GA	30083	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05337	2988 SHALLOWFORD ROAD	MARIETTA	GA	30066	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05580	2035 CANDLER RD	DECATUR	GA	30032	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05758	4371 S COBB DR SE	SMYRNA	GA	30080	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05902	2670 COBB PARKWAY SE	SMYRNA	GA	30080	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06032	595 PIEDMONT AVE NE STE 100	ATLANTA	GA	30308-2480	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06138	2065 S HAIRSTON RD	DECATUR	GA	30035	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06202	6671 COVINGTON HWY	STONECREST	GA	30058	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06205	2945 PANOLA ROAD	STONECREST	GA	30038	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06207	5985 PEACHTREE PKWY	NORCROSS	GA	30092	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06209	1855 HUDSON BRIDGE RD	STOCKBRIDGE	GA	30281	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06330	2464 ROSWELL RD.	MARIETTA	GA	30062	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06481	3584 WESLEY CHAPEL ROAD	DECATUR	GA	30034-5215	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06897	5675 JONESBORO ROAD	LAKE CITY	GA	30260-3804	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07167	5511 CHAMBLEE DUNWOODY RD SUITE A	DUNWOODY	GA	30338-4106	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07394	3740 CASCADE RD SW	ATLANTA	GA	30331	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07478	2781 LAVISTA ROAD	DECATUR	GA	30033-1713	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07608	5435 FIVE FORKS TRICKUM ROAD	STONE MOUNTAIN	GA	30087	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07742	1510 MILSTEAD AVE NE	CONYERS	GA	30012-3877	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07995	4765 REDAN RD	STONE MOUNTAIN	GA	30088	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09271	7935 TARA BLVD	JONESBORO	GA	30236-2205	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09303	2893 PEACHTREE RD NE	ATLANTA	GA	30305-2929	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09452	855 VETERANS MEMORIAL HWY SE	MABLETON	GA	30126	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09620	3800 PRINCETON LAKES PKWY SW	ATLANTA	GA	30331	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09621	315 FAIRVIEW RD	ELLENWOOD	GA	30294-2634	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #09623	896 HWY 81 E	MCDONOUGH	GA	30252	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09630	4617 JONESBORO ROAD	UNION CITY	GA	30291-2048	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10422	3658 ROSWELL RD NW	ATLANTA	GA	30342	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11488	2711 METROPOLITAN PKWY SW	ATLANTA	GA	30315	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11758	6665 HIGHWAY 85	RIVERDALE	GA	30274	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12262	2320 N DRUID HILLS RD NE	BROOKHAVEN	GA	30329	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13641	35 COLLIER ROAD NW SUITE 100	ATLANTA	GA	30309	01/12/2015	04/01/2015	04/30/2025	04/30/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13759	6120 OLD NATIONAL HWY	COLLEGE PARK	GA	30349	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13873	2675 N DECATUR ROAD STE 101	DECATUR	GA	30033	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #15304	1874 PIEDMONT AVE NE STE 100A	ATLANTA	GA	30324	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	01/12/2015	04/01/2015	06/15/2015	05/03/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/12/2015	04/01/2015	06/15/2015	05/03/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/12/2015	04/01/2015		05/03/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/12/2015	04/01/2015	10/11/2016	05/03/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/12/2015	04/01/2015		05/03/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110078A	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at Clifton Road Campus	1365 Clifton Rd NE, Bldg C, Plaza Level	Atlanta	GA	Active
DSH110078AA	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Infusion Center Non-Oncology at EUHM Campus	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078AB	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at Emory Nephrology	1365-A Clifton Road NE	Atlanta	GA	Terminated
DSH110078AC	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at Emory Pulmonary Infusion	1365-A Clifton Road NE	Atlanta	GA	Terminated
DSH110078AD	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Transplant Center Hepatitis C Clinic and Transplant Infusion	1365 Clifton Rd NE, Bldg B, 6th Floor	Atlanta	GA	Active
DSH110078AE	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute BMT Clinic at Clifton Road Campus	1365 Clifton Rd NE, Bldg C, Plaza Level	Atlanta	GA	Active
DSH110078AF	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology Clinic at Clifton Road Campus	1365 Clifton Rd NE, Bldg C	Atlanta	GA	Terminated
DSH110078AG	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology and Medical Oncology Clinic at Clifton Campus	1365 Clifton Rd NE, 2nd floor, Bldg C	Atlanta	GA	Active
DSH110078AH	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology / Oncology Clinic at EUHM Campus	550 Peachtree St NE	Atlanta	GA	Terminated
DSH110078AJ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology / Oncology Clinic at ESJH Campus	5665 Peachtree Dunwoody Road	Atlanta	GA	Active
DSH110078AK	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology / Oncology Clinic at EJCH Campus	6335 Hospital Parkway	Johns Creek	GA	Active
DSH110078AL	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Hematology and Medical Oncology Clinic-Buford	3276 Buford Drive	Buford	GA	Active
DSH110078AM	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at Buford	3276 Buford Drive	Buford	GA	Active
DSH110078AN	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EHM Smyrna / Ancillary services-Imaging	3949 South Cobb Drive	Smyrna	GA	Terminated
DSH110078AP	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EHM Smyrna / Observation	3949 South Cobb Drive	Smyrna	GA	Terminated
DSH110078AQ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EHM Smyrna / Respiratory	3949 South Cobb Drive	Smyrna	GA	Terminated
DSH110078AR	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Heart Failure Center-Arrhythmia	550 Peachtree St. NE	Atlanta	GA	Terminated
DSH110078AS	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (MRI)-Medical Office Tower	550 Peachtree St NE	Atlanta	GA	Terminated
DSH110078AT	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Non-Oncology Infusion Center at Clifton Campus (B2) - Non-Oncology	1365 Clifton Rd NE	Atlanta	GA	Active
DSH110078AU	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Rheumatology Clinic at Clifton Campus	1365 Clifton Rd	Atlanta	GA	Active
DSH110078AV	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	WCI Oncology Clinic and Integrative Oncology and Survivorship Clinic at Clifton Campus - Oncology	1365 Clifton Rd NE	Atlanta	GA	Active
DSH110078AW	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	PHARMACOTHERAPY CLINIC AT CLIFTON - PHARMACOTHERAPY CLINIC AT CLIFTON	1365A CLIFTON RD NE	ATLANTA	GA	Active
DSH110078AX	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL NEURODIAGNOSTICS - EP12 4TH FL NEURODIAGNOSTICS	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078AY	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL NEUROLOGY - EP12 4TH FL NEUROLOGY	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078AZ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 5TH FL NEUROLOGY - EP12 5TH FL NEUROLOGY	12 Executive Park Dr NE	Atlanta	GA	Active
DSH110078B	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at EUHM Campus	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078BA	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL NEUROSURGERY - EP12 4TH FL NEUROSURGERY	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078BB	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 4TH FL REHAB MED - EP12 4TH FL REHAB MED	12 EXECUTIVE PARK DR NE	ATLANTA	GA	Active
DSH110078BC	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EP12 5TH FL PAIN MED - EP12 5TH FL PAIN MED	12 Executive Park Dr NE	Atlanta	GA	Active
DSH110078BD	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 CARDIOLOGY - CLIFTON A2 CARDIOLOGY	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BE	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CHANTILLY CARDIOLOGY - CHANTILLY CARDIOLOGY	1605 CHANTILLY DR NE	ATLANTA	GA	Active
DSH110078BF	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5671 CARDIOLOGY - ESJH 5671 CARDIOLOGY	5671 PEACHTREE DUNWOODY RD, FLOOR 3, STE 300	ATLANTA	GA	Active
DSH110078BG	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 CT SURG - CLIFTON A2 CT SURG	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BH	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 HEART FAILURE - CLIFTON A2 HEART FAILURE	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BJ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A2 VASC SURG - CLIFTON A2 VASC SURG	1365 CLIFTON RD NE, BLDG A FLOOR 2	ATLANTA	GA	Active
DSH110078BK	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 DIABETES EDU - CLIFTON A3 DIABETES EDU	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BL	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 DIABETES MGMT - CLIFTON A3 DIABETES MGMT	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BM	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5671 DIABETES EDU - ESJH 5671 DIABETES EDU	5671 PEACHTREE DUNWOODY RD, FLOOR 2, STE 210	ATLANTA	GA	Active
DSH110078BN	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 ENDOCRINOLOGY - CLIFTON A3 ENDOCRINOLOGY	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BP	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 NEPH - CLIFTON A3 NEPH	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BQ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON A3 PULMONARY - CLIFTON A3 PULMONARY	1365 CLIFTON RD NE, BLDG A FLOOR 3	ATLANTA	GA	Active
DSH110078BR	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CHANTILLY PULMONARY - CHANTILLY PULMONARY	1605 CHANTILLY DR, 3RD FLOOR, SUITE 392	ATLANTA	GA	Active
DSH110078BS	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5673 PULMONARY - ESJH 5673 PULMONARY	5673 PEACHTREE DUNWOODY RD, FLOOR 5, STE 525	ATLANTA	GA	Active
DSH110078BT	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON B1 GASTRO - CLIFTON B1 GASTRO	1365 CLIFTON RD NE, BLDG B FLOOR 1	ATLANTA	GA	Active
DSH110078BU	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5673 7TH FL GASTRO - ESJH 5673 7TH FL GASTRO	5673 Peachtree Dunwoody Rd	Atlanta	GA	Active
DSH110078BV	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON B1 HEPATOLOGY - CLIFTON B1 HEPATOLOGY	1365 CLIFTON RD NE, BLDG B FLOOR 1	ATLANTA	GA	Active
DSH110078BW	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON C2 SURG ONC - CLIFTON C2 SURG ONC	1365 CLIFTON RD NE, BLDG C FLOOR 2	ATLANTA	GA	Active
DSH110078BX	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	SJH Oncology Surg Srvc - ESJH 5665 COLORECTAL, ESJH 5665 SURG ONC, ESJH 5665 WOUND CARE	5665 PEACHTREE DUNWOODY RD NE	Atlanta	GA	Active
DSH110078BY	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	LOCUST GROVE CARDIOLOGY - LOCUST GROVE CARDIOLOGY	4899 BILL GARDNER PKWY	LOCUST GROVE	GA	Active
DSH110078BZ	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	ESJH 5671 ENDOCRINOLOGY - ESJH 5671 ENDOCRINOLOGY	5671 PEACHTREE DUNWOODY RD, FLOOR 2, STE 210	ATLANTA	GA	Active
DSH110078C	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Non-Oncology Infusion Center at Clifton Road Campus (A3)	1365A Clifton Road NE, 3rd Floor, Bldg A	Atlanta	GA	Active
DSH110078CA	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EJC Plaza 2nd Floor Cardiology - EJCH PLAZA 2ND FL CARDIOLOGY EUHM, EJCH PLAZA 2ND FL CARDIOVASCULAR IMAGING	6335 Hospital Pkwy	Johns Creek	GA	Active
DSH110078CB	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	CLIFTON C2 P&R SURG - CLIFTON C2 P&R SURG	1365 CLIFTON RD NE, BLDG C FLOOR 2	ATLANTA	GA	Active
DSH110078D	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at Emory Endocrinology	1365 Clifton Road, N.E.	Atlanta	GA	Terminated
DSH110078E	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Non-Oncology Infusion Center at Clifton Campus (B1)	1365B Clifton Road NE, Bldg B	Atlanta	GA	Active
DSH110078F	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at EJCH Campus	6335 Hospital Parkway	Johns Creek	GA	Active
DSH110078G	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Winship Cancer Institute Infusion Center at ESJH Campus	5665 Peachtree Dunwoody Rd	Atlanta	GA	Active
DSH110078H	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Southern Heart Cardiac Imaging-Peachtree City	101 World Drive	Peachtree City	GA	Active
DSH110078J	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Southern Heart Cardiac Technicals at Locust Grove	4899 Bill Gardner Parkway	Locust Grove	GA	Active
DSH110078K	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Southern Heart Cardiac Imaging at Stockbridge	1050 Eagles Landing Parkway	Stockbridge	GA	Active
DSH110078L	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Southern Heart Cardiac Imaging at Riverdale	6507 Professional Place	Riverdale	GA	Active
DSH110078M	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at EUHM Campus	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078N	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Decatur	2801 N Decatur Rd	Decatur	GA	Terminated
DSH110078P	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Eastside	1608 Tree Lane	Snellville	GA	Terminated
DSH110078Q	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Hillandale	5461 Hillandale Dr	Lithonia	GA	Terminated
DSH110078R	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Rockdale	1400 Wellbrook Circle NE	Conyers	GA	Terminated
DSH110078S	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Villa Rica	401 Permian Way	Villa Rica	GA	Terminated
DSH110078T	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Heart and Vascular Imaging at Smyrna	1060 Windy Hill Road	Smyrna	GA	Active
DSH110078U	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory University Hospital Midtown Imaging at Buford	3276 Buford Drive, Suite 202	Buford	GA	Active
DSH110078V	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Emory Imaging Stockbridge	3625 GA Hwy 138	Stockbridge	GA	Active
DSH110078W	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (CT) - Medical Office Tower	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078X	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (General Diagnostics) - Medical Office Tower	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078Y	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	EUHM Radiology (PET) - Medical Office Tower	550 Peachtree Street NE	Atlanta	GA	Terminated
DSH110078Z	Child	DSH	EMORY UNIVERSITY HOSPITAL MIDTOWN	Internal Medicine at MOT Rheumatology	550 Peachtree Street NE	Atlanta	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Daunt-Samford, Ava E CFO Emory Healthcare 4046864918	Urbistondo, Lisa Vice President & CFO Emory Decatur, Emory Hillandale 4045015025	5/5/2025 6:51 AM
Addresses	Shipping Address	Insert	Change Request		Emory Pharmacy Access Solutions 550 Peachtree Street NE STE OL5P10 Atlanta, GA 30308	1/22/2025 11:55 AM
Details	Last Recertification Date	Update	Recertification	9/6/2023 10:53:19 AM	9/5/2024 12:54:29 PM	9/5/2024 12:54 PM
Contacts	Primary Contact	Update	Profile Change Request	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory University Hospital Midtown 4046862147	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory Healthcare 4046862147	5/1/2024 2:16 PM
Contacts	Authorizing Official	Update	AO Change Request	Anderson, Greg E. CFO Emory 4046862823	Daunt-Samford, Ava E CFO Emory Healthcare 4046864918	1/29/2024 7:29 AM
Contacts	Primary Contact	Update	Profile Change Request	Kchao, Sydney Assistant Director of Pharmacy, Finance Emory University Hospital Midtown 4046862147	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory University Hospital Midtown 4046862147	1/10/2024 10:20 AM
Addresses	Shipping Address	Insert	Change Request		Safecor Health 4060 Business Park Drive Columbus, OH 43204	11/28/2023 8:09 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 9:20:56 AM	9/6/2023 10:53:19 AM	9/6/2023 10:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/22/2023 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003283804A	6/22/2023 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	6/22/2023 2:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1528767506	6/22/2023 2:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	6/22/2023 2:00 PM
Addresses	Shipping Address	Insert	Change Request		Winship at Emory Midtown - Receiving 575 West Peachtree Street Atlanta GA, GA 30308	6/1/2023 7:48 AM
Addresses	Shipping Address	Insert	Change Request		Winship at Emory Midtown Home Health Pharmacy 550 Peachtree Street NE STE 06.5P30 Atlanta, GA 30308	4/12/2023 11:09 AM
Addresses	Shipping Address	Insert	Change Request		Winship at Emory Midtown Hospital Pharmacy 550 Peachtree Street NE STE 06.5P30 Atlanta, GA 30308	4/12/2023 11:09 AM
Addresses	Shipping Address	Insert	Change Request		The Pharmacy at Winship Emory Midtown 550 Peachtree Street NE STE OL5P10 Atlanta, GA 30308	4/12/2023 11:09 AM
Addresses	Shipping Address	Insert	Change Request		Non-Oncology Infusion Pharmacy at Building A 1365A Clifton Road NE, 3rd Floor, Bldg A A3446 Atlanta, GA 30322	3/14/2023 8:00 AM
Addresses	Shipping Address	Delete	Recertification	Winship Cancer Institute Infusion Center at Clifton Road Campus 1365 Clifton Rd NE Plaza Level CPL036 Atlanta, GA 30322		8/31/2022 9:20 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 9:34:21 PM	8/31/2022 9:20:56 AM	8/31/2022 9:20 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 1:01:30 PM	9/9/2021 9:34:21 PM	9/9/2021 9:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 3:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003241260A	12/10/2020 3:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	12/10/2020 3:11 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427669670	11/2/2020 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	11/2/2020 5:17 PM
Addresses	Shipping Address	Insert	Change Request		Winship Cancer Institute Infusion Center at Clifton Road Campus 1365 Clifton Rd NE Plaza Level CPL036 Atlanta, GA 30322	10/23/2020 8:13 AM
Addresses	Shipping Address	Insert	Recertification		Emory Specialty Pharmacy 550 Peachtree St NE Suite 1760 Atlanta, GA 30308	9/8/2020 1:01 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033582531	9/8/2020 1:01 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 1:01 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1073837167	9/8/2020 1:01 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 1:01 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144203563	9/8/2020 1:01 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 1:01 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1144203563 ( )		9/8/2020 1:01 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1033582531 ( )		9/8/2020 1:01 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1073837167 ( )		9/8/2020 1:01 PM
Details	Last Recertification Date	Update	Recertification	9/13/2019 7:40:58 AM	9/8/2020 1:01:30 PM	9/8/2020 1:01 PM
Details	Last Recertification Date	Update	Recertification	9/3/2018 9:00:04 AM	9/13/2019 7:40:58 AM	9/13/2019 7:40 AM
Contacts	Primary Contact	Update	Change Request	Norman, Christy VP Pharmacy Services Emory Healthcare Inc 4046862304	Kchao, Sydney Assistant Director of Pharmacy, Finance Emory University Hospital Midtown 4046862147	11/13/2018 7:27 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 8:29:38 PM	9/3/2018 9:00:04 AM	9/3/2018 9:00 AM
Addresses	Shipping Address	Insert	Change Request		The Pharmacy at Emory 1750 Gambrell Drive Suite T203 Atlanta, GA 30322	11/20/2017 8:53 AM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/15/2017 8:29:38 PM	11/15/2017 8:29 PM
Contacts	Primary Contact	Update	Change Request	OWENS, DANIEL CORPORATE CONTROLLER 4046862812	Norman, Christy VP Pharmacy Services Emory Healthcare Inc 4046862304	10/4/2017 12:44 PM
Contacts	Authorizing Official	Update		Anderson, Greg E. CFO 4046862823	Anderson, Greg E. CFO Emory 4046862823	9/24/2017 7:33 PM
Contacts	Authorizing Official	Insert			Anderson, Greg E. CFO 4046862823	7/17/2017 6:05 PM
Addresses	Shipping Address	Delete		The Pharmacy at Emory 1365 Clifton Road NE Suite A2000 Atlanta, GA 30322		5/3/2017 12:43 PM
Addresses	Main Address	Insert			550 PEACHTREE STREET, NE ATLANTA, GA 30308-2209	5/3/2017 12:43 PM
Addresses	Shipping Address	Insert			The Pharmacy at Emory 1365 Clifton Road NE Suite A2000 Atlanta, GA 30322	5/3/2017 12:43 PM
Addresses	Shipping Address	Insert			Emory University Hospital Midtown 550 Peachtree St NE Atlanta, GA 30308	5/3/2017 12:43 PM
Addresses	Shipping Address	Insert			Safecor 317 New Boston St., Suite 100 Woburn, MA 01801-4226	5/3/2017 12:43 PM
Addresses	Shipping Address	Insert			The Pharmacy at Emory Midtown 550 Peachtree St. NE Room L103A Atlanta, GA 30308	5/3/2017 12:43 PM
Medicaid Billing	Medicaid: Number	Update		00000503A	000000503A	4/19/2017 8:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/16/2017 1:45 PM
Medicaid Billing	Medicaid: Number	Insert			003166275A	1/16/2017 1:45 PM
Medicaid Billing	Medicaid: State	Insert			GA	1/16/2017 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/16/2017 1:45 PM
Medicaid Billing	Medicaid: Number	Insert			099009370A	1/16/2017 1:45 PM
Medicaid Billing	Medicaid: State	Insert			GA	1/16/2017 1:45 PM
Medicaid Billing	NPI: Number	Insert			1033582531	1/16/2017 1:45 PM
Medicaid Billing	NPI: Number	Insert			1073837167	1/16/2017 1:45 PM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 7:47 AM
Medicaid Billing	NPI: Number	Insert			1144203563	10/5/2015 5:52 PM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 10:14 AM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM	8/28/2014 12:00:00 AM	8/28/2014 11:47 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/10/2013 12:00:00 AM	9/10/2013 8:28 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	4/30/2012 7:39 AM
Contacts	Primary Contact	Insert			OWENS, DANIEL CORPORATE CONTROLLER 4046862812	6/24/2010 2:36 PM
Details	Comments Public	Insert			7/31/09 UPDATED ENTITY NAME (WAS EMORY CRAWFORD LONG HOSPITAL) 6/24/10 ADDED SHIP TO ADDRESS	6/24/2010 2:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	3/1/2006 11:07 AM
Medicaid Billing	Medicaid: Number	Insert			00000503A	3/1/2006 11:07 AM
Medicaid Billing	Medicaid: State	Insert			GA	3/1/2006 11:07 AM
Details	Last Recertification Date	Insert				3/1/2006 11:07 AM
Details	Grant Number	Insert				3/1/2006 11:07 AM
Details	340B ID	Insert			DSH110078	3/1/2006 11:07 AM
Details	Is Authorizing Official EHB Data	Insert				3/1/2006 11:07 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/1/2006 11:07 AM
Details	Medicare Provider Number	Insert			110078	3/1/2006 11:07 AM
Details	Entity Name	Insert			EMORY UNIVERSITY HOSPITAL MIDTOWN	3/1/2006 11:07 AM
Details	Program Code	Insert			DSH	3/1/2006 11:07 AM
Details	Entity Subname	Insert				3/1/2006 11:07 AM
Dates	Participating Approval Date	Insert			3/1/2006 12:00:00 AM	3/1/2006 11:07 AM
Details	State	Insert			Active	3/1/2006 11:07 AM
Dates	Registration Date	Insert			3/1/2006 12:00:00 AM	3/1/2006 11:07 AM
Dates	Signed By Date	Insert			2/27/2006 12:00:00 AM	3/1/2006 11:07 AM
Dates	Start Date	Insert			4/1/2006 12:00:00 AM	3/1/2006 11:07 AM
Terminations	Termination Comments	Insert				3/1/2006 11:07 AM
Terminations	Termination Date	Insert				3/1/2006 11:07 AM
Terminations	Termination Effective Date	Insert				3/1/2006 11:07 AM
Terminations	Termination Reason	Insert				3/1/2006 11:07 AM
Details	Comments Public	Insert			7/31/09 UPDATED ENTITY NAME (WAS EMORY CRAWFORD LONG HOSPITAL) 6/24/10 ADDED SHIP TO ADDRESS	3/1/2006 11:07 AM