Covered Entity Details

DSH110091B Piedmont Rockdale Hospital, Inc. (Active) - information as of 5/23/2025 12:20:16 AM

Main Details

Name

Piedmont Rockdale Hospital, Inc.

Subdivision Name

Piedmont Rockdale Hospital - Outpatient Speech Therapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110091B

Medicare Provider Number

110091

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/14/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/22/2019

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Piedmont Healthcare
Stewart Witherell, CFO
(770) 918-3101

Primary Contact

Piedmont Rockdale Hospital, Inc.
Amanda Meriwether Miller, Director of Pharmacy
(770) 918-3752

Addresses

Street Address

1290 Wellbrook Circle
Conyers, GA 30012

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	000001603A	1306355680

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.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH110091A	Child	DSH	Piedmont Rockdale Hospital, Inc.	Piedmont Rockdale Hospital - Outpatient Physical Therapy	1290 Wellbrook Circle	Conyers	GA	Active
DSH110091B	Child	DSH	Piedmont Rockdale Hospital, Inc.	Piedmont Rockdale Hospital - Outpatient Speech Therapy	1290 Wellbrook Circle	Conyers	GA	Active
DSH110091C	Child	DSH	Piedmont Rockdale Hospital, Inc.	Piedmont Oncology Institute - Oncology	1412 Milstead Ave NE	Conyers	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/31/2023 8:53:14 AM	8/12/2024 9:46:51 AM	8/12/2024 9:46 AM
Contacts	Signed By	Update	Profile Change Request	Wynn, Marty CFO Piedmont Rockdale Hospital 7709183101	Wynn, Marty CFO Piedmont Eastside Medical Center 7707362420	1/17/2024 9:13 AM
Contacts	Authorizing Official	Update	Change Request	Roberts, Justin CFO Piedmont Rockdale Hospital 7709183101	Witherell, Stewart CFO Piedmont Healthcare 7709183101	12/1/2023 12:56 PM
Details	Last Recertification Date	Update	Recertification	9/9/2022 9:49:58 AM	8/31/2023 8:53:14 AM	8/31/2023 8:53 AM
Contacts	Authorizing Official	Update	AO Change Request	Wynn, Marty CFO Piedmont Rockdale Hospital 7709183101	Roberts, Justin CFO Piedmont Rockdale Hospital 7709183101	8/30/2023 11:37 AM
Details	Last Recertification Date	Update	Recertification	8/20/2021 11:01:37 AM	9/9/2022 9:49:58 AM	9/9/2022 9:49 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 7:56:07 AM	8/20/2021 11:01:37 AM	8/20/2021 11:01 AM
Medicaid Billing	NPI: State	Update	Recertification		GA	9/10/2020 7:56 AM
Details	Last Recertification Date	Update	Recertification	8/19/2019 9:34:54 AM	9/10/2020 7:56:07 AM	9/10/2020 7:56 AM
Details	Last Recertification Date	Update	Recertification		8/19/2019 9:34:54 AM	8/19/2019 9:34 AM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Details	Entity Name	Update	Change Request	ROCKDALE MEDICAL CENTER	Piedmont Rockdale Hospital, Inc.	3/6/2019 8:11 AM
Contacts	Signed By	Insert	New Registration		Wynn, Marty CFO Piedmont Rockdale Hospital 7709183101	1/22/2019 2:42 PM
Details	340B ID	Update	New Registration		DSH110091B	1/22/2019 2:42 PM
Details	Entity Subname	Update	New Registration	Piedmont Rockdale Hospital	Piedmont Rockdale Hospital - Outpatient Speech Therapy	1/22/2019 2:42 PM
Dates	Participating Approval Date	Update	New Registration		1/22/2019 2:42:31 PM	1/22/2019 2:42 PM
Details	State	Update	New Registration	Pending	Approved	1/22/2019 2:42 PM
Dates	Signed By Date	Update	New Registration		1/21/2019 9:41:19 AM	1/22/2019 2:42 PM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	1/22/2019 2:42 PM
Addresses	Main Address	Insert	New Registration		1290 Wellbrook Circle Conyers, GA 30012	1/14/2019 5:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/14/2019 5:29 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000001603A	1/14/2019 5:29 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/14/2019 5:29 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1306355680	1/14/2019 5:29 PM
Contacts	Primary Contact	Insert	New Registration		Miller, Amanda Meriwether Director of Pharmacy Piedmont Rockdale Hospital, Inc. 7709183752	1/14/2019 5:29 PM
Contacts	Authorizing Official	Insert	New Registration		Wynn, Marty CFO Piedmont Rockdale Hospital 7709183101	1/14/2019 5:29 PM
Details	Last Recertification Date	Insert	New Registration			1/14/2019 5:29 PM
Details	Grant Number	Insert	New Registration			1/14/2019 5:29 PM
Details	340B ID	Insert	New Registration			1/14/2019 5:29 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/14/2019 5:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/14/2019 5:29 PM
Details	Medicare Provider Number	Insert	New Registration		110091	1/14/2019 5:29 PM
Details	Entity Name	Insert	New Registration		ROCKDALE MEDICAL CENTER	1/14/2019 5:29 PM
Details	Program Code	Insert	New Registration		DSH	1/14/2019 5:29 PM
Details	Entity Subname	Insert	New Registration		Piedmont Rockdale Hospital	1/14/2019 5:29 PM
Dates	Participating Approval Date	Insert	New Registration			1/14/2019 5:29 PM
Details	State	Insert	New Registration		Pending	1/14/2019 5:29 PM
Dates	Registration Date	Insert	New Registration		1/14/2019 5:29:01 PM	1/14/2019 5:29 PM
Dates	Signed By Date	Insert	New Registration			1/14/2019 5:29 PM
Dates	Start Date	Insert	New Registration			1/14/2019 5:29 PM
Terminations	Termination Comments	Insert	New Registration			1/14/2019 5:29 PM
Terminations	Termination Date	Insert	New Registration			1/14/2019 5:29 PM
Terminations	Termination Effective Date	Insert	New Registration			1/14/2019 5:29 PM
Terminations	Termination Reason	Insert	New Registration			1/14/2019 5:29 PM