Covered Entity Details

CH04039P MEDLINK GEORGIA, INC (Active) - information as of 4/29/2025 1:41:03 AM

Main Details

Name

MEDLINK GEORGIA, INC

Subdivision Name

MedLink Monroe

Type

HRSA-Funded Health Center

Site ID

BPS-H80-036772

340B ID

CH04039P

Grant Number

H80CS00427

Additional Details

Current Program Status

Active

Registration Date

4/11/2016

Participating Start Date

7/1/2016

Participating Approval Date

4/13/2016

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

Medlink Georgia, Inc
Dave Ward, CEO
(706) 788-3234

Primary Contact

Medlink Georgia, Inc
Dennis Kimbrell, Director of Pharmacy Services
(706) 788-3234 Ext: 2204

Addresses

Street Address

705 Breedlove Dr, Ste 100
Monroe, GA 30655

Billing Address
Same as Street Address

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	003176317A,003167129A,003202598A	1669833364,1801262720,1245732254

Shipping Addresses

Same as Street Address

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH040390	Active	BPS-H80-003904	MEDLINK GEORGIA, INC.	Medlink Colbert	11 CHARLIE MORRIS RD	COLBERT	GA
CH04039A	Active	BPS-H80-002112	MEDLINK GEORGIA, INC	MEDLINK BOWMAN	206 E Church St	Bowman	GA
CH04039AA	Active	BPS-H80-035114	Medlink Georgia, Inc	MedLink Rabun Family Foot Care	180 Legacy Pt STE 102	Clayton	GA
CH04039AB	Active	BPS-H80-034482	Medlink Georgia, Inc	MedLink Toccoa	711 Rose Ln	Toccoa	GA
CH04039AC	Active	BPS-H80-035600	MEDLINK GEORGIA INC	MedLink Warrior Wellness Center	2648 Highway 129 N,	Cleveland	GA
CH04039AD	Active	BPS-H80-035518	MEDLINK GEORGIA INC	MedLink Cleveland Family Foot Care	2109 Highway 129 S, STE C,	Cleveland	GA
CH04039AE	Active	BPS-H80-036065	MEDLINK GEORGIA INC	MedLink Rabun Women's Health Center	563 Mountain City Rd	Clayton	GA
CH04039AF	Active	BPS-H80-036607	MEDLINK GEORGIA, INC.	MedLink Oconee	1160 Capital Ave. STE 105,	Watkinsville	GA
CH04039AG	Active	BPS-H80-037024	MEDLINK GEORGIA, INC.	MedLink Athens	2000 Prince Ave	Athens	GA
CH04039AH	Active	BPS-H80-038953	MEDLINK GEORGIA, INC.	MedLink Hawks School Based Health Center	2035 Calvary Church Rd	Gainesville	GA
CH04039AJ	Active	BPS-H80-039330	MEDLINK GEORGIA, INC.	MedLink Coile School Based Health Center	110 Old Elberton Rd	Athens	GA
CH04039AK	Active	BPS-H80-039329	MEDLINK GEORGIA, INC.	MedLink HT Edwards School Based Health Center	440 Dearing Ext, Bldg 3	Athens	GA
CH04039B	Active	BPS-H80-038020	MEDLINK GEORGIA, INC	MedLink Banks	112 Banks Road STE 1	Commerce	GA
CH04039C	Active	BPS-H80-003403	MEDLINK GEORGIA, INC	MEDLINK RABUN	896 Highway 441 S	Clayton	GA
CH04039D	Active	BPS-H80-002487	MEDLINK GEORGIA, INC	MEDLINK HARTWELL	63 W. GIBSON ST	HARTWELL	GA
CH04039E	Active	BPS-H80-024492	MEDLINK GEORGIA, INC	MedLink Gainesville	520 Jesse Jewell Pkwy SE	Gainesville	GA
CH04039H	Active	BPS-H80-014543	MEDLINK GEORGIA, INC	MEDLINK ROYSTON	930 Franklin Springs St	ROYSTON	GA
CH04039J	Active	BPS-H80-001994	MEDLINK GEORGIA, INC	MEDLINK OGLETHORPE	247 Union Point St	Lexington	GA
CH04039L	Active	BPS-H80-015247	MEDLINK GEORGIA, INC	MedLink Winder	133 W Athens ST	Winder	GA
CH04039M	Active	BPS-H80-013508	MEDLINK GEORGIA, INC	MedLink Habersham	396 Historic Highway 441 N	Demorest	GA
CH04039N	Active	BPS-H80-021314	MEDLINK GEORGIA, INC	MedLink White	17 WHITE ST	CLEVELAND	GA
CH04039P	Active	BPS-H80-036772	MEDLINK GEORGIA, INC	MedLink Monroe	705 Breedlove Dr, Ste 100	Monroe	GA
CH04039Q	Active	BPS-H80-033547	MEDLINK GEORGIA, INC	MedLink Danielsville	306 Courthouse Sq	Danielsville	GA
CH04039R	Active	BPS-H80-018749	MEDLINK GEORGIA, INC	MedLink Winder Women's Health Center	137 W Athens St Ste 103	Winder	GA
CH04039S	Terminated	BPS-H80-021314	Medlink Georgia, Inc	MedLink White	17 White St	Cleveland	GA
CH04039T	Active	BPS-H80-036500	Medlink Georgia, Inc	MedLink Commerce	611 Hospital Rd	Commerce	GA
CH04039U	Active	BPS-H80-022087	Medlink Georgia, Inc	MedLink Rabun North	773 N Main St	Clayton	GA
CH04039V	Active	BPS-H80-034074	Medlink Georgia, Inc	MedLink Lawrenceville	980 Lawrenceville Hwy	Lawrenceville	GA
CH04039W	Active	BPS-H80-032036	Medlink Georgia, Inc	MedLink Jefferson	2748 Winder Hwy	Jefferson	GA
CH04039X	Active	BPS-H80-033069	Medlink Georgia, Inc	MedLink Suches	56 Firewater Ln	Suches	GA
CH04039Y	Active	BPS-H80-034727	Medlink Georgia, Inc	MedLink Hartwell Family Foot Care	1087 E Franklin St STE G	Hartwell	GA
CH04039Z	Active	BPS-H80-021735	Medlink Georgia, Inc	MedLink Commerce Family Foot Care	613 Hospital Rd	Commerce	GA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH040390	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/01/2019	12/02/2019
CH040390	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/01/2019	12/02/2019
CH040390	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2019
CH040390	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/01/2019	12/02/2019
CH040390	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/01/2019	12/02/2019
CH040390	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/01/2019	12/02/2019
CH040390	AVITA PHARMACY 1040	AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10	6100 CORPORATE BLVD STE 250	BATON ROUGE	LA	70808	07/01/2019
CH040390	AVITA PHARMACY 1046	LONG'S DRUGS OF SANDERSVILLE, GEORGIA, I	2140 PEACHTREE RD NW STE 232	ATLANTA	GA	30309	07/01/2023
CH040390	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2023
CH040390	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2023
CH040390	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2023
CH040390	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2023
CH040390	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2023
CH040390	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2023
CH040390	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2023
CH040390	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2023
CH040390	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2023
CH040390	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2023
CH040390	CENTERWELL PHARMACY, INC.	11010 FLORIDA CROWN DRIVE, SUITE 200		ORLANDO	FL	32824	01/01/2024
CH040390	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	01/01/2024
CH040390	CLEVELAND DRUG CO INC	DBA CLEVELAND DRUG CO	184 W KYTLE ST STE A	CLEVELAND	GA	30528	01/01/2018
CH040390	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD STE 1400		ST PETERSBURG	FL	33716-2338	04/01/2015	07/11/2018
CH040390	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	04/01/2015	07/11/2018
CH040390	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2023
CH040390	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2023
CH040390	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2023
CH040390	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/01/2022
CH040390	DIXIE CITY PHARMACY	DIXIE CITY PHARMACY	1079 JESSE JEWELL PKWY SW	GAINESVILLE	GA	30501-3050	10/01/2013	06/05/2018
CH040390	ECKERD CORPORATION	RITE AID #11827	39 EAST MAY STREET, SUITE I	WINDER	GA	30680	10/01/2013	03/01/2018
CH040390	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/01/2019	12/02/2019
CH040390	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/01/2019	12/02/2019
CH040390	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/01/2019
CH040390	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/01/2019
CH040390	FRED'S PHARMACY # 2129	718 ATHENS RD		LEXINGTON	GA	30648-1907	01/01/2017	10/16/2019
CH040390	FRED'S PHARMACY # 2959	1567 N. CHEROKEE ROAD		SOCIAL CIRCLE	GA	30025	01/01/2017	05/10/2018
CH040390	FRED'S PHARMACY #1394	15 COLBERT BUSINESS PKWY. W		COLBERT	GA	30628	01/01/2017	01/10/2019
CH040390	FRED'S PHARMACY #1831	534 BELL CREEK ROAD		HIAWASSEE	GA	30546	01/01/2017	05/10/2018
CH040390	FRED'S PHARMACY #1874	203 N. MAIN STREET		GREENSBORO	GA	30642	01/01/2017	05/10/2018
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07759	308 SOUTH US HIGHWAY 441	CLAYTON	GA	30525	04/01/2017
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03798	549 N MAIN ST	CORNELIA	GA	30531	04/01/2017
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07782	8895 US HIGHWAY 29 SOUTH	HULL	GA	30646	04/01/2017
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05613	21 NORTH CAROLINA ST.	HARTWELL	GA	30643	01/01/2020
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04518	920 E. ROBERT TOOMBS AVE.	WASHINGTON	GA	30673	01/01/2020
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03777	312 SO. BROAD STREET	MONROE	GA	30655	07/01/2021
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 4164	1680 OLD PENDERGRASS RD.	JEFFERSON	GA	30549	07/01/2021
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03776	232 ELBERT STREET	ELBERTON	GA	30635	07/01/2023
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04555	4044 LEXINGTON RD	ATHENS	GA	30605	07/01/2023
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04389	6 WEST MAY STREET	WINDER	GA	30680	07/01/2023
CH040390	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04190	959 BIG A ROAD	TOCCOA	GA	30577	04/01/2025
CH040390	HARTWELL RX INC	DBA HARTWELL DRUGS	118 ATHENS STREET	HARTWELL	GA	30643	04/01/2016	12/09/2016
CH04039D	HARTWELL RX INC	DBA HARTWELL DRUGS	118 ATHENS STREET	HARTWELL	GA	30643	04/01/2016	04/01/2016
CH040390	LEXINGTON PHARMACIES INC.	SKRIP SHOPPE PHARMACY	778 ATHENS RD.	LEXINGTON	GA	30648	05/06/2019
CH040390	LONG'S DEKALB HEALTH PHARMACY	AVITA PHARMACY 1045	1428 SCOTT BLVD	DECATUR	GA	30030	07/01/2019
CH040390	LONGS DRUGS OF LEXINGTON	D/B/A AVITA PHARMACY 1051	1216 W MAIN ST STE D	LEXINGTON	SC	29072-2453	07/01/2019
CH040390	MADDEN'S PHARMACY INC.	101 COLLEGE AVE.		ELBERTON	GA	30635	10/01/2016	07/13/2017
CH040390	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/01/2024
CH040390	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/01/2024
CH040390	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/01/2022	10/01/2022
CH040390	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2023
CH040390	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/01/2023
CH040390	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2023
CH040390	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2023
CH040390	RITE AID OF GEORGIA, INC.	RITE AID #1753	859 FRANKLIN SPRINGS STREET	ROYSTON	GA	30662	10/01/2013	03/01/2018
CH040390	SELF-MED RX CLAYTON PHARMACY	100 S MAIN ST	PO BOX 686	CLAYTON	GA	30525-5480	10/01/2013
CH040390	SKRIP SHOPPE PHARMACY	778 ATHENS RD	PO BOX 281	LEXINGTON	GA	30648-3064	10/01/2013	05/06/2019
CH040390	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2018
CH040390	WAL-MART PHARMACY 10-0003	30983 HWY 441 SOUTH		COMMERCE	GA	30529	10/01/2018
CH040390	WAL-MART PHARMACY 10-0510	400 SHALLOWFORD RD NW		GAINESVILLE	GA	30504	10/01/2018
CH040390	WAL-MART PHARMACY 10-0520	440 ALANTA HIGHWAY, N.W.		WINDER	GA	30680	04/01/2014
CH040390	WAL-MART PHARMACY 10-0780	2050 W SPRING ST		MONROE	GA	30655	07/01/2021
CH040390	WAL-MART PHARMACY 10-1111	1572 ANDERSON HWY		HARTWELL	GA	30643	10/01/2018
CH040390	WAL-MART PHARMACY 10-1122	3886 HIGHWAY 17 ALT		EASTANOLLEE	GA	30538	10/01/2018
CH040390	WAL-MART PHARMACY 10-1403	250 FURNITURE DRIVE		CORNELIA	GA	30531	10/01/2018
CH040390	WAL-MART PHARMACY 10-1701	955 ELBERT STREET		ELBERTON	GA	30635	10/01/2018
CH040390	WAL-MART PHARMACY 10-2753	1455 HIGHWAY 441 SOUTH		CLAYTON	GA	30525	04/01/2014
CH040390	WAL-MART PHARMACY 10-2811	4375 LEXINGTON ROAD		ATHENS (E)	GA	30605	10/01/2018
CH040390	WAL-MART PHARMACY 10-4616	260 DONALD E THURMOND PARKWAY		CLEVELAND	GA	30528	01/01/2018
CH040390	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2018
CH040390	WALGREEN CO	DBA: WALGREENS #11166	18 COLLEGE AVE	ELBERTON	GA	30635	10/18/2011	02/25/2025
CH040390	WALGREEN CO	DBA: WALGREENS #11791	2100 N BROAD STREET	COMMERCE	GA	30529	10/18/2011
CH040390	WALGREEN CO.	DBA: WALGREENS # 07134	110 HAWTHORNE AVE	ATHENS	GA	30606-2814	10/18/2011
CH040390	WALGREEN CO.	DBA: WALGREENS # 09706	472 S ENOTA DR NE	GAINESVILLE	GA	30501	10/18/2011
CH040390	WALGREEN CO.	DBA: WALGREENS #12464	355 HIGHWAY 441 S	CLAYTON	GA	30525	10/18/2011
CH040390	WALGREEN CO.	DBA: WALGREENS #12726	10 EAST MAY STREET	WINDER	GA	30680	10/18/2011
CH040390	WALGREEN CO.	DBA; WALGREENS #12886	3355 LEXINGTON ROAD	ATHENS	GA	30605	10/18/2011	02/21/2024
CH040390	WALGREEN CO.	DBA: WALGREENS #12502	876 BIG A ROAD	TOCCOA	GA	30577	01/01/2018
CH040390	WALGREEN CO.	RITE AID #11827	39 E MAY ST, STE 1	WINDER	GA	30680	03/26/2018	06/25/2018
CH040390	WALGREEN CO.	WALGREENS #19011	859 FRANKLIN SPRINGS ST	ROYSTON	GA	30662	03/26/2018
CH040390	WALGREEN CO.	DBA: WALGREENS #18250	379 N MAIN ST	CLEVELAND	GA	30528	10/01/2018
CH040390	WALGREEN CO.	WALGREENS #19561	1235 WASHINGTON ST	CLARKESVILLE	GA	30523	07/01/2020
CH040390	WALGREEN CO.	DBA: WALGREENS # 06374	649 SHALLOWFORD RD NW	GAINESVILLE	GA	30504	07/01/2020
CH040390	WALGREEN CO.	WALGREENS #17732	380 GENERAL DANIEL AVE N	DANIELSVILLE	GA	30633	07/01/2020
CH040390	WALGREEN CO.	WALGREENS #19973	189 QUALITY FOODS SHOPPING CTR	CORNELIA	GA	30531-5788	07/01/2020
CH040390	WALGREEN CO.	DBA: WALGREENS # 05446	2990 FIVE FORKS TRICKUM RD	LAWRENCEVILLE	GA	30044	01/01/2021
CH040390	WALGREENS OF NORTH CAROLINA INC.	DBA: WALGREENS #16105	19 SAWMILL VILLAGE LANE	FRANKLIN	NC	28734	01/01/2018
CH040390	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/01/2022
CH040390	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2022
CH040390	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2022
CH040390	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023
CH040390	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CH040390	WILKES APOTHECARY	D/B/A: FIEVET PHARMACY	115 E ROBERT TOOMBS AVE P. O. BOX 626	WASHINGTON	GA	30673-1737	10/01/2013	12/12/2016

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/4/2024 1:14:04 PM	2/11/2025 7:52:54 AM	2/11/2025 7:52 AM
Addresses	Main Address	Update	Change Request	705 Breedlove Dr, Ste 100 Monroe, GA 30655-2054	705 Breedlove Dr, Ste 100 Monroe, GA 30655	9/3/2024 4:22 PM
Details	Entity Subname	Update	Change Request	MedLink Walton	MedLink Monroe	9/3/2024 4:22 PM
Details	Last Recertification Date	Update	Recertification	2/1/2023 8:18:52 AM	2/4/2024 1:14:04 PM	2/4/2024 1:14 PM
Addresses	Main Address	Update	Change Request	704 Breedlove Dr Ste B Monroe, GA 30655-2054	705 Breedlove Dr, Ste 100 Monroe, GA 30655-2054	7/5/2023 8:55 AM
Details	Last Recertification Date	Update	Recertification	2/1/2022 6:56:14 PM	2/1/2023 8:18:52 AM	2/1/2023 8:18 AM
Details	Last Recertification Date	Update	Recertification	2/6/2021 8:32:53 AM	2/1/2022 6:56:14 PM	2/1/2022 6:56 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	2/6/2021 8:32 AM
Medicaid Billing	NPI: State	Update	Recertification		GA	2/6/2021 8:32 AM
Medicaid Billing	NPI: State	Update	Recertification		GA	2/6/2021 8:32 AM
Details	Last Recertification Date	Update	Recertification	2/5/2020 7:35:00 AM	2/6/2021 8:32:53 AM	2/6/2021 8:32 AM
Addresses	Main Address	Update	Change Request	704 Breedlove Dr Monroe, GA 30655-2054	704 Breedlove Dr Ste B Monroe, GA 30655-2054	9/25/2020 1:20 PM
Details	Last Recertification Date	Update	Recertification	1/30/2019 7:51:02 AM	2/5/2020 7:35:00 AM	2/5/2020 7:35 AM
Addresses	Main Address	Update	OPA Edit	704 Breedlove Drive Monroe, GA 30655-2054	704 Breedlove Dr Monroe, GA 30655-2054	3/13/2019 7:19 AM
Addresses	Main Address	Update	Change Request	924 West Spring Street, Suite A Monroe, GA 30655-1751	704 Breedlove Drive Monroe, GA 30655-2054	3/13/2019 7:18 AM
Details	Entity Subname	Update	Change Request	MedLink Monroe	MedLink Walton	3/13/2019 7:18 AM
Details	Last Recertification Date	Update	Recertification	2/8/2018 9:45:17 AM	1/30/2019 7:51:02 AM	1/30/2019 7:51 AM
Contacts	Primary Contact	Update		Kimbrell, Dennis Director of Pharmacy Services Medlink Georgia, Inc 7067883234	Kimbrell, Dennis Director of Pharmacy Services Medlink Georgia, Inc 7067883234-2204	9/25/2018 11:40 AM
Contacts	Primary Contact	Update	Change Request	Forman, Joey W Strategic Initiative Program Manager MedLink Georgia, Inc 7067883234-1025	Kimbrell, Dennis Director of Pharmacy Services Medlink Georgia, Inc 7067883234	9/25/2018 5:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/29/2018 8:44 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003202598A	5/29/2018 8:44 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	5/29/2018 8:44 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1245732254	5/29/2018 8:44 PM
Contacts	Primary Contact	Update	Recertification	Ward, Dave CEO Medlink Georgia, Inc 7067883234	Forman, Joey W Strategic Initiative Program Manager MedLink Georgia, Inc 7067883234-1025	2/8/2018 9:45 AM
Details	Last Recertification Date	Update	Recertification	1/26/2017 12:00:00 AM	2/8/2018 9:45:17 AM	2/8/2018 9:45 AM
Details	Is Authorizing Official EHB Data	Update	Recertification	False		2/8/2018 9:45 AM
Contacts	Authorizing Official	Update	Profile Change Request	Ward, Dave CFO Medlink Georgia, Inc 7067883234	Ward, Dave CEO Medlink Georgia, Inc 7067883234	10/6/2017 8:44 AM
Contacts	Primary Contact	Update	Profile Change Request	Ward, Dave CFO Medlink Georgia, Inc 7067883234	Ward, Dave CEO Medlink Georgia, Inc 7067883234	10/6/2017 8:44 AM
Contacts	Signed By	Update	Profile Change Request	Ward, Dave CFO Medlink Georgia, Inc 7067883234	Ward, Dave CEO Medlink Georgia, Inc 7067883234	10/6/2017 8:44 AM
Contacts	Authorizing Official	Update		Ward, Dave CFO 7067883234	Ward, Dave CFO Medlink Georgia, Inc 7067883234	10/5/2017 8:46 PM
Contacts	Primary Contact	Update		Ward, Dave CFO 7067883234	Ward, Dave CFO Medlink Georgia, Inc 7067883234	10/5/2017 8:46 PM
Contacts	Signed By	Update		Ward, Dave CFO 7067883234	Ward, Dave CFO Medlink Georgia, Inc 7067883234	10/5/2017 8:46 PM
Contacts	Authorizing Official	Insert			Ward, Dave CFO 7067883234	6/22/2017 1:42 PM
Contacts	Primary Contact	Insert			Ward, Dave CFO 7067883234	6/22/2017 1:42 PM
Contacts	Signed By	Insert			Ward, Dave CFO 7067883234	6/22/2017 1:42 PM
Addresses	Main Address	Insert			924 West Spring Street, Suite A Monroe, GA 30655-1751	6/2/2017 2:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/2/2017 2:49 PM
Medicaid Billing	Medicaid: Number	Insert			003176317A	6/2/2017 2:49 PM
Medicaid Billing	Medicaid: State	Insert			GA	6/2/2017 2:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/2/2017 2:49 PM
Medicaid Billing	Medicaid: Number	Insert			003167129A	6/2/2017 2:49 PM
Medicaid Billing	Medicaid: State	Insert			GA	6/2/2017 2:49 PM
Medicaid Billing	NPI: Number	Insert			1669833364	6/2/2017 2:49 PM
Medicaid Billing	NPI: Number	Insert			1801262720	6/2/2017 2:49 PM
Details	Last Recertification Date	Update			1/26/2017 12:00:00 AM	1/26/2017 7:44 AM
Dates	Participating Approval Date	Update			4/13/2016 12:00:00 AM	4/13/2016 2:25 PM
Details	State	Update		Pending	Active	4/13/2016 2:25 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	4/13/2016 2:25 PM
Details	340B ID	Update		ONLINE_REG_59586	CH04039P	4/12/2016 2:50 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_59586	4/11/2016 2:53 PM
Details	Last Recertification Date	Insert				4/11/2016 2:53 PM
Details	Grant Number	Insert			H80CS00427	4/11/2016 2:53 PM
Details	340B ID	Insert			ONLINE_REG	4/11/2016 2:53 PM
Details	Is Authorizing Official EHB Data	Insert			False	4/11/2016 2:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/11/2016 2:53 PM
Details	Medicare Provider Number	Insert				4/11/2016 2:53 PM
Details	Entity Name	Insert			MEDLINK GEORGIA, INC	4/11/2016 2:53 PM
Details	Program Code	Insert			CH	4/11/2016 2:53 PM
Details	Entity Subname	Insert			MedLink Monroe	4/11/2016 2:53 PM
Dates	Participating Approval Date	Insert				4/11/2016 2:53 PM
Details	State	Insert			Pending	4/11/2016 2:53 PM
Dates	Registration Date	Insert			4/11/2016 12:00:00 AM	4/11/2016 2:53 PM
Dates	Signed By Date	Insert			4/11/2016 12:00:00 AM	4/11/2016 2:53 PM
Dates	Start Date	Insert				4/11/2016 2:53 PM
Terminations	Termination Comments	Insert				4/11/2016 2:53 PM
Terminations	Termination Date	Insert				4/11/2016 2:53 PM
Terminations	Termination Effective Date	Insert				4/11/2016 2:53 PM
Terminations	Termination Reason	Insert				4/11/2016 2:53 PM

340B Drug Pricing Program Database