Covered Entity Details

DSH110079F GRADY MEMORIAL HOSPITAL (Terminated) - information as of 6/6/2025 12:34:02 PM

Main Details

Name

GRADY MEMORIAL HOSPITAL

Subdivision Name

NORTH DEKALB HEALTH CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110079F

Medicare Provider Number

110079

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

9/5/2007

Participating Start Date

10/1/2002

Participating Approval Date

9/5/2007

Last Recertification Date

8/23/2016

Termination Date
Termination Reason

1/1/2018
Site closure

Contacts

Authorizing Official

Grady Health System
John Haupert, Chief Executive Officer
(404) 616-4254

Primary Contact

Grady Health System
Val Dixon Hallman, Director Pharmacy Administration
(404) 616-3576

Addresses

Street Address

3807 CLAIRMONT RD, SE
CHAMBLEE, GA 30341

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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	00000855A,937307B
		1700891355

Shipping Addresses

Shipping Address 1

North Dekalb Health Center Pharmacy
3807 Clairmont Road
Chamblee, GA 30341

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110079A	Child	DSH	GRADY MEMORIAL HOSPITAL	Kirkwood Health Center	1863 Memorial Drive SE	Atlanta	GA	Active
DSH110079AA	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - ENT Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AB	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - GYN Oncology	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AC	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Hem-Oncology Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079AD	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Emergency Care Center	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AE	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - Adult Outpatient Clinic	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AF	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Outpatient Rehab	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AG	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Sickle Cell Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AH	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Asthma Ctr-Excellence	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AJ	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Cerebral Palsy & Autism Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AK	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Child Abuse Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AL	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - ACT Team	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AM	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Radiology	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AN	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY BEHAVIORAL HEALTH OP - Adult Outpt Internal Med Clinic	10 PARK PL NE	ATLANTA	GA	Active
DSH110079AP	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Pediatric Appointment Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AQ	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Adolescent Clinic	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AR	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital - Respiratory Care	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079AS	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY HEALTH SYSTEM - Geriatric Program	1000 White St. SW	ATLANTA	GA	Active
DSH110079AT	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology IR	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AU	Child	DSH	GRADY MEMORIAL HOSPITAL	Cascade Outpatient Center - Cascade Road Outpatient Center	3355 Cascade Rd.	Atlanta	GA	Active
DSH110079AV	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology Ultrasound	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AW	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology MRI	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AX	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology OR	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AY	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology CT	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079AZ	Child	DSH	GRADY MEMORIAL HOSPITAL	CAMP CREEK COMPREHENSIVE CARE CENTE - Ambulatory Care Coordination	3896 PRINCETON LAKES WAY SW	ATLANTA	GA	Active
DSH110079BA	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Radiology X Ray	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BB	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Pre- Post- PACU	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BC	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - GA Aide Mobile Mammo	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079BD	Child	DSH	GRADY MEMORIAL HOSPITAL	Behavioral Health South Clinic - PSY FC North-South Outpatient	5600 Stonewall Tell Road	College Park	GA	Active
DSH110079BE	Child	DSH	GRADY MEMORIAL HOSPITAL	CORRELL PAVILION - Correll Surgery	80 GILMER ST SE	ATLANTA	GA	Active
DSH110079C	Child	DSH	GRADY MEMORIAL HOSPITAL	East Point Health Center	1595 W Cleveland Ave	East Point	GA	Active
DSH110079D	Child	DSH	GRADY MEMORIAL HOSPITAL	Asa G. Yancey Health Center	1247 Donald Lee Hollowell Pkwy NW	Atlanta	GA	Active
DSH110079F	Child	DSH	GRADY MEMORIAL HOSPITAL	NORTH DEKALB HEALTH CENTER	3807 CLAIRMONT RD, SE	CHAMBLEE	GA	Terminated
DSH110079G	Child	DSH	GRADY MEMORIAL HOSPITAL	Hughes Spalding Childrens Hospital	35 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079H	Child	DSH	GRADY MEMORIAL HOSPITAL	Ponce De Leon Center	341 Ponce De Leon Ave NE	Atlanta	GA	Active
DSH110079L	Child	DSH	GRADY MEMORIAL HOSPITAL	Behavioral Health Outpatient Center	10 Park Place NE	Atlanta	GA	Terminated
DSH110079M	Child	DSH	GRADY MEMORIAL HOSPITAL	North Fulton Health Center	7741 Roswell Rd	Sandy Springs	GA	Active
DSH110079N	Child	DSH	GRADY MEMORIAL HOSPITAL	Brookhaven Health Center	2695 Buford Hwy NE	Atlanta	GA	Active
DSH110079P	Child	DSH	GRADY MEMORIAL HOSPITAL	Edward C. Loughlin Radiation-Oncology Center	145 Edgewood Ave SE	Atlanta	GA	Active
DSH110079Q	Child	DSH	GRADY MEMORIAL HOSPITAL	Walk-In Center	56 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079R	Child	DSH	GRADY MEMORIAL HOSPITAL	Manuel J. Maloof Imaging Center	56 Jesse Hill Jr Drive SE	Atlanta	GA	Active
DSH110079S	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Ophthalmology Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079T	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Oral Surgery Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079U	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Digital Mammography Services	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079V	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Surgery Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079W	Child	DSH	GRADY MEMORIAL HOSPITAL	GRADY EMS - Mobile Integrated Health	745 MEMORIAL DR SE	ATLANTA	GA	Active
DSH110079X	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Infusion Center	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079Y	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - GI Clinic	80 Gilmer Street SE	Atlanta	GA	Active
DSH110079Z	Child	DSH	GRADY MEMORIAL HOSPITAL	Correll Pavilion - Orthopedic Trauma Clinic	80 Gilmer Street SE	Atlanta	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/23/2017 12:00:00 AM	11/20/2017 2:40 PM
Details	State	Update	Recertification	Active	To Be Terminated	11/20/2017 2:40 PM
Terminations	Termination Date	Update	Recertification		1/1/2018 12:00:00 AM	11/20/2017 2:40 PM
Terminations	Termination Effective Date	Update	Recertification		6/26/2017 12:00:00 AM	11/20/2017 2:40 PM
Terminations	Termination Reason	Update	Recertification		Site closure	11/20/2017 2:40 PM
Contacts	Authorizing Official	Update		Haupert, John Chief Executive Officer 4046164254	Haupert, John Chief Executive Officer Grady Health System 4046164254	11/1/2017 11:17 AM
Contacts	Primary Contact	Update		Hallman, Val Director Pharmacy Administration 4046163576	Hallman, Val Dixon Director Pharmacy Administration Grady Health System 4046163576	10/31/2017 3:57 PM
Contacts	Authorizing Official	Update		YOUNG, MICHAEL A. CHIEF EXECUTIVE OFFICER 4046164252	Haupert, John Chief Executive Officer 4046164254	7/11/2017 8:40 AM
Contacts	Primary Contact	Insert			Hallman, Val Director Pharmacy Administration 4046163576	7/11/2017 8:40 AM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 5:20 PM
Addresses	Main Address	Insert			3807 CLAIRMONT RD, SE CHAMBLEE, GA 30341	8/23/2016 5:20 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/19/2015 4:26 PM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	8/19/2015 12:00:00 AM	8/19/2015 4:26 PM
Details	Last Recertification Date	Update		9/6/2013 9:59:16 AM	8/22/2014 12:00:00 AM	8/22/2014 12:00 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/6/2013 9:59:16 AM	9/6/2013 9:59 AM
Addresses	Shipping Address	Insert			North Dekalb Health Center Pharmacy 3807 Clairmont Road Chamblee, GA 30341	5/29/2012 12:01 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 12:01 PM
Medicaid Billing	Medicaid: Number	Update		00000855C	00000855A	4/16/2012 2:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/16/2012 2:01 PM
Medicaid Billing	Medicaid: Number	Insert			937307B	4/16/2012 2:01 PM
Medicaid Billing	Medicaid: State	Insert			GA	4/16/2012 2:01 PM
Medicaid Billing	NPI: Number	Insert			1700891355	4/16/2012 2:01 PM
Dates	Participating Approval Date	Update		9/5/2007 7:06:38 PM	9/5/2007 12:00:00 AM	4/16/2012 2:01 PM
Contacts	Authorizing Official	Insert			YOUNG, MICHAEL A. CHIEF EXECUTIVE OFFICER 4046164252	12/19/2011 5:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/5/2007 7:02 PM
Medicaid Billing	Medicaid: Number	Insert			00000855C	9/5/2007 7:02 PM
Medicaid Billing	Medicaid: State	Insert			GA	9/5/2007 7:02 PM
Details	Last Recertification Date	Insert				9/5/2007 7:02 PM
Details	Grant Number	Insert				9/5/2007 7:02 PM
Details	340B ID	Insert			DSH110079F	9/5/2007 7:02 PM
Details	Is Authorizing Official EHB Data	Insert				9/5/2007 7:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/5/2007 7:02 PM
Details	Medicare Provider Number	Insert			110079	9/5/2007 7:02 PM
Details	Entity Name	Insert			GRADY MEMORIAL HOSPITAL	9/5/2007 7:02 PM
Details	Program Code	Insert			DSH	9/5/2007 7:02 PM
Details	Entity Subname	Insert			NORTH DEKALB HEALTH CENTER	9/5/2007 7:02 PM
Dates	Participating Approval Date	Insert			9/5/2007 7:06:38 PM	9/5/2007 7:02 PM
Details	State	Insert			Active	9/5/2007 7:02 PM
Dates	Registration Date	Insert			9/5/2007 12:00:00 AM	9/5/2007 7:02 PM
Dates	Signed By Date	Insert				9/5/2007 7:02 PM
Dates	Start Date	Insert			10/1/2002 12:00:00 AM	9/5/2007 7:02 PM
Terminations	Termination Comments	Insert				9/5/2007 7:02 PM
Terminations	Termination Date	Insert				9/5/2007 7:02 PM
Terminations	Termination Effective Date	Insert				9/5/2007 7:02 PM
Terminations	Termination Reason	Insert				9/5/2007 7:02 PM