Covered Entity Details

DSH110115D WellStar ATLANTA MEDICAL CENTER (Terminated) - information as of 4/23/2025 10:54:01 PM

Main Details

Name

WellStar ATLANTA MEDICAL CENTER

Subdivision Name

Cancer Center Mammography

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110115D

Medicare Provider Number

110115

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/12/2017

Participating Start Date

4/1/2017

Participating Approval Date

3/7/2017

Last Recertification Date

8/29/2022

Termination Date
Termination Reason

10/1/2022
Other

Contacts

Authorizing Official

Wellstar Atlanta Medical Center
Thomas M Morris, Chief Operating Officer
(770) 853-9009

Primary Contact

Wellstar Atlanta Medical Center
Valerie Bandy, Director of Pharmacy
(470) 533-9100

Addresses

Street Address

320 Parkway Drive NE, Suite 102
Atlanta, GA 30312

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?
No

Shipping Addresses

Shipping Address 1

Atlanta Medical Center
303 Parkway Dr NE
Atlanta, GA 30312

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
DSH110115A	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Sleep Lab	1136 Cleveland Ave, Suite 400	East Point	GA	Terminated
DSH110115B	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Cardiac Catheterization Laboratory	1136 Cleveland Ave, Suite 415	East Point	GA	Terminated
DSH110115C	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Outpatient surgery center	285 Boulevard NE, L1	Atlanta	GA	Terminated
DSH110115D	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Cancer Center Mammography	320 Parkway Drive NE, Suite 102	Atlanta	GA	Terminated
DSH110115E	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Wound Care Center	285 Boulevard NE, L3	Atlanta	GA	Terminated
DSH110115F	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Sheffield Clinic	265 Boulevard NE, 2nd Floor	Atlanta	GA	Terminated
DSH110115G	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Imaging Center Camp Creek	3890 Redwine Road	Atlanta	GA	Terminated
DSH110115H	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Nutrition and Food Services	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115J	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Anesthesiology	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115K	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Nuclear Medicine	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115L	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Vascular Institute	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115M	Child	DSH	WellStar ATLANTA MEDICAL CENTER	General Surgery	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115N	Child	DSH	WellStar ATLANTA MEDICAL CENTER	CATSCAN	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115P	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Radiology Diagnostic	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115Q	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Cath Pacer Procedures	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115R	Child	DSH	WellStar ATLANTA MEDICAL CENTER	GI Lab Special Procedure	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115S	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Emergency Department	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115T	Child	DSH	WellStar ATLANTA MEDICAL CENTER	OP Surgery CTR	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115U	Child	DSH	WellStar ATLANTA MEDICAL CENTER	Recovery Room PACU	1170 Cleveland Avenue	East Point	GA	Terminated
DSH110115V	Child	DSH	WellStar ATLANTA MEDICAL CENTER	IV Therapy Unit	1170 Cleveland Avenue	East Point	GA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/1/2022 12:00:00 AM	9/22/2022 2:01 PM
Details	State	Update	Termination Request	Active	To Be Terminated	9/22/2022 2:01 PM
Terminations	Termination Comments	Update	Termination Request		There’s a change in ownership to Wellstar Kennestone 10-1-22 and Wellstar Atlanta Medical Center is closing 11-1-22.	9/22/2022 2:01 PM
Terminations	Termination Date	Update	Termination Request		10/1/2022 12:00:00 AM	9/22/2022 2:01 PM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2022 12:00:00 AM	9/22/2022 2:01 PM
Terminations	Termination Reason	Update	Termination Request		Other	9/22/2022 2:01 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 10:38:54 AM	8/29/2022 11:10:12 AM	8/29/2022 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 9:07:24 AM	8/25/2021 10:38:54 AM	8/25/2021 10:38 AM
Contacts	Authorizing Official	Update	AO Change Request	Downs, Stuart D VP / Chief Operating Officer WellStar Atlanta Medical Center 4042654184	Morris, Thomas M Chief Operating Officer Wellstar Atlanta Medical Center 7708539009	4/26/2021 12:09 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 12:31:37 PM	8/27/2020 9:07:24 AM	8/27/2020 9:07 AM
Contacts	Primary Contact	Update	Change Request	Doshi, Snehal VP Pharmacy Services WellStar Health System 4706440322	Bandy, Valerie Director of Pharmacy Wellstar Atlanta Medical Center 4705339100	4/7/2020 7:26 AM
Contacts	Primary Contact	Update	Change Request	Pedreira, Michael Pharmacy Director WellStar Atlanta Medical Center 4042654499	Doshi, Snehal VP Pharmacy Services WellStar Health System 4706440322	1/31/2020 7:50 PM
Contacts	Authorizing Official	Update	AO Change Request	Limbaugh, Jason CFO WellStar Atlanta Medical Center 4042654857	Downs, Stuart D VP / Chief Operating Officer WellStar Atlanta Medical Center 4042654184	1/2/2020 7:07 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 10:53:18 AM	8/26/2019 12:31:37 PM	8/26/2019 12:31 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 10:01:35 AM	8/21/2018 10:53:18 AM	8/21/2018 10:53 AM
Details	Last Recertification Date	Update	Recertification		12/5/2017 10:01:35 AM	12/5/2017 10:01 AM
Details	Entity Name	Update	Recertification	ATLANTA MEDICAL CENTER	WellStar ATLANTA MEDICAL CENTER	11/14/2017 1:20 PM
Contacts	Primary Contact	Update	Recertification	Pedreira, Michael Interim Pharmacy Director 4042654499	Pedreira, Michael Pharmacy Director WellStar Atlanta Medical Center 4042654499	11/14/2017 1:20 PM
Contacts	Authorizing Official	Update		Limbaugh, Jason CFO 4042654857	Limbaugh, Jason CFO WellStar Atlanta Medical Center 4042654857	11/14/2017 1:10 PM
Contacts	Signed By	Update		Limbaugh, Jason CFO 4042654857	Limbaugh, Jason CFO WellStar Atlanta Medical Center 4042654857	11/14/2017 1:10 PM
Contacts	Authorizing Official	Insert			Limbaugh, Jason CFO 4042654857	8/9/2017 2:26 PM
Contacts	Signed By	Insert			Limbaugh, Jason CFO 4042654857	8/9/2017 2:26 PM
Contacts	Primary Contact	Update		Bendinelli, Michael Pharmacy Director 4042654517	Pedreira, Michael Interim Pharmacy Director 4042654499	6/6/2017 3:08 PM
Addresses	Main Address	Insert			320 Parkway Drive NE, Suite 102 Atlanta, GA 30312	6/6/2017 3:07 PM
Addresses	Shipping Address	Insert			Atlanta Medical Center 303 Parkway Dr NE Atlanta, GA 30312	6/6/2017 3:07 PM
Contacts	Primary Contact	Insert			Bendinelli, Michael Pharmacy Director 4042654517	4/19/2017 8:51 AM
Dates	Participating Approval Date	Update			3/7/2017 12:00:00 AM	3/7/2017 6:17 PM
Details	State	Update		Pending	Active	3/7/2017 6:17 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	3/7/2017 6:17 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74609	DSH110115D	2/3/2017 6:53 AM
Details	Entity Subname	Update		Cancer Center Mammography / Cancer Center Mammography	Cancer Center Mammography	2/3/2017 6:53 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74609	1/12/2017 10:53 AM
Details	Last Recertification Date	Insert				1/12/2017 10:53 AM
Details	Grant Number	Insert				1/12/2017 10:53 AM
Details	340B ID	Insert				1/12/2017 10:53 AM
Details	Is Authorizing Official EHB Data	Insert				1/12/2017 10:53 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2017 10:53 AM
Details	Medicare Provider Number	Insert			110115	1/12/2017 10:53 AM
Details	Entity Name	Insert			ATLANTA MEDICAL CENTER	1/12/2017 10:53 AM
Details	Program Code	Insert			DSH	1/12/2017 10:53 AM
Details	Entity Subname	Insert			Cancer Center Mammography / Cancer Center Mammography	1/12/2017 10:53 AM
Dates	Participating Approval Date	Insert				1/12/2017 10:53 AM
Details	State	Insert			Pending	1/12/2017 10:53 AM
Dates	Registration Date	Insert			1/12/2017 12:00:00 AM	1/12/2017 10:53 AM
Dates	Signed By Date	Insert			1/12/2017 12:00:00 AM	1/12/2017 10:53 AM
Dates	Start Date	Insert				1/12/2017 10:53 AM
Terminations	Termination Comments	Insert				1/12/2017 10:53 AM
Terminations	Termination Date	Insert				1/12/2017 10:53 AM
Terminations	Termination Effective Date	Insert				1/12/2017 10:53 AM
Terminations	Termination Reason	Insert				1/12/2017 10:53 AM