Covered Entity Details

DSH110143A COBB HOSPITAL, INC. (Active) - information as of 4/29/2025 11:55:14 PM

Main Details

Name

COBB HOSPITAL, INC.

Subdivision Name

WELLSTAR CHEMO INFUSION OF AUSTELL

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110143A

Medicare Provider Number

110143

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2016

Participating Start Date

10/1/2016

Participating Approval Date

8/23/2016

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Wellstar Cobb Hospital
Felix Soto Izaguirre, Chief Financial Officer
(470) 732-5039

Primary Contact

Wellstar Health System
Sarah Oliver, 340B Program Director
(470) 956-4931

Addresses

Street Address

1700 HOSPITAL SOUTH DRIVE
SUITE 302
AUSTELL, GA 30106-8116

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	000000426A,521899833A	1467420448,1821275629

Shipping Addresses

Shipping Address 1

COBB HOSPITAL, INC.
3950 AUSTELL ROAD
AUSTELL, GA 30106

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
DSH110143A	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR CHEMO INFUSION OF AUSTELL	1700 HOSPITAL SOUTH DRIVE	AUSTELL	GA	Active
DSH110143B	Child	DSH	COBB HOSPITAL, INC.	Kennestone Cancer Center / Wellstar Cobb Infusion Therapy Tower	340 Kennestone Hospital Blvd Suite 100	Marietta	GA	Active
DSH110143C	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB OUTPATIENT / Stat Cancer Clinic	1700 Hospital South Drive	AUSTELL	GA	Active
DSH110143D	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB / Cardiac Diagnostics	1700 HOSPITAL SOUTH DRIVE	AUSTELL	GA	Active
DSH110143E	Child	DSH	WELLSTAR COBB HOSPITAL	WELLSTAR COBB OUTPATIENT / Wound Clinic	1605 MULKEY ROAD	AUSTELL	GA	Terminated
DSH110143F	Child	DSH	WELLSTAR COBB HOSPITAL	WellStar Cobb Outpatient / Burn Clinic	1605 Milkey Road Suite A	Austell	GA	Terminated
DSH110143G	Child	DSH	WELLSTAR COBB HOSPITAL	WellStar Cobb Outpatient / Wellness Counseling Services	1625 HOSPITAL NORTH DRIVE	AUSTELL	GA	Terminated
DSH110143H	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Roswell	4500 Hospital Blvd	ROSWELL	GA	Active
DSH110143J	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Austell	1700 HOSPITAL SOUTH DR	AUSTELL	GA	Active
DSH110143K	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Douglasville	6002 PROFESSIONAL PKWY	DOUGLASVILLE	GA	Active
DSH110143L	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Cartersville	100 MARKET PLACE BLVD	CARTERSVILLE	GA	Active
DSH110143M	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GEORGIA ONCOLOGY CENTERS - Northwest Georgia Oncology Paulding	144 BILL CARRUTH PKWY	HIRAM	GA	Active
DSH110143N	Child	DSH	WELLSTAR COBB HOSPITAL	WELLSTAR COBB HOSPITAL ASC VININGS - GENERAL SURGERY	4441 ATLANTA ROAD SE	SMYRNA	GA	Terminated
DSH110143P	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB HOSPITAL HEART FAILUR - Wellstar Cobb Heart Failure Clinic	1791 MULKEY RD	AUSTELL	GA	Active
DSH110143Q	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GA ONCOLOGY CENTERS - Northwest Georgia Oncology Cherokee	1120 WELLSTAR WAY	HOLLY SPRINGS	GA	Active
DSH110143R	Child	DSH	COBB HOSPITAL, INC.	NORTHWEST GA ONCOLOGY CTRS AT VHP - NORTHWEST GA ONCOLOGY CTRS AT VHP	4441 ATLANTA RD SE	SMYRNA	GA	Active
DSH110143S	Child	DSH	COBB HOSPITAL, INC.	WELLSTAR COBB RADIATION ONCOLOGY - Radiation Therapy	1800 HOSPITAL SOUTH DR	AUSTELL	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Oliver, Sarah 340B Program Manager WellStar Health System 4709564931	Oliver, Sarah 340B Program Director Wellstar Health System 4709564931	10/15/2024 7:29 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 9:43:32 AM	8/22/2024 4:44:09 PM	8/22/2024 4:44 PM
Details	Entity Name	Update	Change Request	WELLSTAR COBB HOSPITAL	COBB HOSPITAL, INC.	6/12/2024 12:07 PM
Addresses	Shipping Address	Insert	Change Request		COBB HOSPITAL, INC. 3950 AUSTELL ROAD AUSTELL, GA 30106	6/11/2024 8:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		000000426A	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		521899833A	12/8/2023 3:18 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467420448	12/8/2023 3:18 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1821275629	12/8/2023 3:18 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	12/8/2023 3:18 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 2:53:08 PM	8/21/2023 9:43:32 AM	8/21/2023 9:43 AM
Contacts	Primary Contact	Update	PC Change Request	Doshi, Snehal SVP Ancillary and Support Svcs WellStar Health System 4706440322	Oliver, Sarah 340B Program Manager WellStar Health System 4709564931	6/22/2023 8:04 AM
Contacts	Authorizing Official	Update	AO Change Request	King, Heath Austin CFO Wellstar Cobb Hospital 4707325039	Soto Izaguirre, Felix Chief Financial Officer Wellstar Cobb Hospital 4707325039	1/31/2023 2:24 PM
Contacts	Primary Contact	Update	Profile Change Request	Doshi, Snehal VP Pharmacy Services WellStar Health System 4706440322	Doshi, Snehal SVP Ancillary and Support Svcs WellStar Health System 4706440322	1/12/2023 1:00 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 3:35:23 PM	8/29/2022 2:53:08 PM	8/29/2022 2:53 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 11:13:01 AM	8/25/2021 3:35:23 PM	8/25/2021 3:35 PM
Details	Last Recertification Date	Update	Recertification	8/23/2019 1:44:03 PM	8/27/2020 11:13:01 AM	8/27/2020 11:13 AM
Contacts	Primary Contact	Update	Change Request	Emamifar, Amir Director of Pharmacy WellStar Cobb Hospital 4707324151	Doshi, Snehal VP Pharmacy Services WellStar Health System 4706440322	4/23/2020 4:50 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 11:26:02 AM	8/23/2019 1:44:03 PM	8/23/2019 1:44 PM
Addresses	Main Address	Update	Change Request	1700 HOSPITAL SOUTH DRIVE SUITE 102 AUSTELL, GA 30106-8116	1700 HOSPITAL SOUTH DRIVE SUITE 302 AUSTELL, GA 30106-8116	1/14/2019 10:12 AM
Details	Last Recertification Date	Update	Recertification	12/6/2017 2:26:13 PM	8/28/2018 11:26:02 AM	8/28/2018 11:26 AM
Contacts	Authorizing Official	Update	Profile Change Request	King, Heath Austin CFO Wellstar Health System 4707325039	King, Heath Austin CFO Wellstar Cobb Hospital 4707325039	8/28/2018 11:06 AM
Contacts	Authorizing Official	Update	AO Change Request	ETHERIDGE, DAROLD CFO WellStar Cobb Hospital 4707325039	King, Heath Austin CFO Wellstar Health System 4707325039	8/22/2018 8:40 AM
Details	Last Recertification Date	Update	Recertification		12/6/2017 2:26:13 PM	12/6/2017 2:26 PM
Details	Entity Name	Update	Recertification	COBB HOSPITAL AND MEDICAL CENTER	WELLSTAR COBB HOSPITAL	12/6/2017 2:23 PM
Contacts	Primary Contact	Update	Recertification	Emamifar, Amir Direcor of Pharmacy 4707324151	Emamifar, Amir Director of Pharmacy WellStar Cobb Hospital 4707324151	12/6/2017 2:23 PM
Contacts	Authorizing Official	Update		ETHERIDGE, DAROLD CFO 4707325039	ETHERIDGE, DAROLD CFO WellStar Cobb Hospital 4707325039	10/4/2017 4:22 PM
Contacts	Signed By	Update		ETHERIDGE, DAROLD CFO 4707325039	ETHERIDGE, DAROLD CFO WellStar Cobb Hospital 4707325039	10/4/2017 4:22 PM
Contacts	Authorizing Official	Insert			ETHERIDGE, DAROLD CFO 4707325039	8/9/2017 1:20 PM
Contacts	Signed By	Insert			ETHERIDGE, DAROLD CFO 4707325039	8/9/2017 1:20 PM
Contacts	Primary Contact	Update		Doshi, Snehal VP Pharmacy Services 4706440322	Emamifar, Amir Direcor of Pharmacy 4707324151	3/29/2017 12:00 PM
Addresses	Main Address	Insert			1700 HOSPITAL SOUTH DRIVE SUITE 102 AUSTELL, GA 30106-8116	3/29/2017 12:00 PM
Contacts	Primary Contact	Insert			Doshi, Snehal VP Pharmacy Services 4706440322	8/23/2016 10:58 AM
Dates	Participating Approval Date	Update			8/23/2016 12:00:00 AM	8/23/2016 10:58 AM
Details	State	Update		Pending	Active	8/23/2016 10:58 AM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	8/23/2016 10:58 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_71442	DSH110143A	8/15/2016 3:17 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_71442	7/12/2016 2:16 PM
Details	Last Recertification Date	Insert				7/12/2016 2:16 PM
Details	Grant Number	Insert				7/12/2016 2:16 PM
Details	340B ID	Insert				7/12/2016 2:16 PM
Details	Is Authorizing Official EHB Data	Insert				7/12/2016 2:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/12/2016 2:16 PM
Details	Medicare Provider Number	Insert			110143	7/12/2016 2:16 PM
Details	Entity Name	Insert			COBB HOSPITAL AND MEDICAL CENTER	7/12/2016 2:16 PM
Details	Program Code	Insert			DSH	7/12/2016 2:16 PM
Details	Entity Subname	Insert			WELLSTAR CHEMO INFUSION OF AUSTELL	7/12/2016 2:16 PM
Dates	Participating Approval Date	Insert				7/12/2016 2:16 PM
Details	State	Insert			Pending	7/12/2016 2:16 PM
Dates	Registration Date	Insert			7/12/2016 12:00:00 AM	7/12/2016 2:16 PM
Dates	Signed By Date	Insert			7/12/2016 12:00:00 AM	7/12/2016 2:16 PM
Dates	Start Date	Insert				7/12/2016 2:16 PM
Terminations	Termination Comments	Insert				7/12/2016 2:16 PM
Terminations	Termination Date	Insert				7/12/2016 2:16 PM
Terminations	Termination Effective Date	Insert				7/12/2016 2:16 PM
Terminations	Termination Reason	Insert				7/12/2016 2:16 PM