Covered Entity Details

DSH110164 Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center (Terminated) - information as of 4/28/2025 12:40:38 AM

Main Details

Name

Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110164

Medicare Provider Number

110164

Additional Details

Current Program Status

Terminated

Registration Date

1/9/2023

Participating Start Date

4/1/2023

Participating Approval Date

1/11/2023

Last Recertification Date

8/14/2024

Termination Date
Termination Reason

1/1/2025
DSH percentage below statutory minimum

Contacts

Authorizing Official

Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center
Alisha R Neal, Chief Financial Officer PMM & PMN
(478) 464-8140

Primary Contact

Coliseum Medical Center, Inc d/b/a Piedmont Macon Medical Center
Cheryl Stapleton, Director of Pharmacy
(478) 765-4818

Addresses

Street Address

350 Hospital Drive
Macon, GA 31217

Billing Address

Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center
350 Hospital Drive
Macon, GA 31217

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	000000459A	1598719643

Shipping Addresses

Shipping Address 1

Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center
350 Hospital Drive
Macon, GA 31217

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	WALGREEN CO	DBA: WALGREENS #11940	274 W CLINTON ST	GRAY	GA	31032	04/07/2023	07/01/2023	01/01/2025	01/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06950	1280 GRAY HWY	MACON	GA	31211-1921	04/07/2023	07/01/2023	11/09/2023	12/08/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06560	3888 VINEVILLE AVE	MACON	GA	31204-1865	01/08/2024	04/01/2024	01/01/2025	01/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07229	4305 MERCER UNIVERSITY DRIVE	MACON	GA	31206-4117	01/08/2024	04/01/2024	01/01/2025	01/01/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		11/20/2024 12:00:00 AM	12/3/2024 11:04 AM
Details	State	Update	Termination Request	Active	To Be Terminated	12/3/2024 11:04 AM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	12/3/2024 11:04 AM
Terminations	Termination Effective Date	Update	Termination Request		11/22/2024 12:00:00 AM	12/3/2024 11:04 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	12/3/2024 11:04 AM
Details	Last Recertification Date	Update	Recertification	9/3/2023 10:52:42 PM	8/14/2024 9:42:23 AM	8/14/2024 9:42 AM
Contacts	Authorizing Official	Update	Profile Change Request	Neal, Alisha R Chief Financial Officer PMM & PMN Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 4784648140	Neal, Alisha R Chief Financial Officer PMM & PMN Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center 4784648140	6/11/2024 9:50 AM
Contacts	Signed By	Update	Profile Change Request	Neal, Alisha R Chief Financial Officer PMM & PMN Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 4784648140	Neal, Alisha R Chief Financial Officer PMM & PMN Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center 4784648140	6/11/2024 9:50 AM
Addresses	Billing Address	Update	Change Request	Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 350 Hospital Drive Macon, GA 31217	Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center 350 Hospital Drive Macon, GA 31217	4/29/2024 7:53 AM
Addresses	Shipping Address	Update	Change Request	Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 350 Hospital Drive Macon, GA 31217	Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center 350 Hospital Drive Macon, GA 31217	4/29/2024 7:53 AM
Details	Entity Name	Update	Change Request	Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center	Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center	4/29/2024 7:53 AM
Contacts	Primary Contact	Update	Profile Change Request	Stapleton, Cheryl Director of Pharmacy Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center 4787654818	Stapleton, Cheryl Director of Pharmacy Coliseum Medical Center, Inc d/b/a Piedmont Macon Medical Center 4787654818	4/22/2024 7:37 AM
Contacts	Primary Contact	Update	Profile Change Request	Stapleton, Cheryl Director of Pharmacy Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 4787654818	Stapleton, Cheryl Director of Pharmacy Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center 4787654818	4/22/2024 5:37 AM
Addresses	Main Address	Update	Recertification	350 HOSPITAL DRIVE MACON, GA 31203	350 Hospital Drive Macon, GA 31217	9/3/2023 10:52 PM
Addresses	Billing Address	Update	Recertification	Coliseum Medical Center, LLC d/b/a Piedmont 350 Hospital Drive Macon, GA 31217	Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 350 Hospital Drive Macon, GA 31217	9/3/2023 10:52 PM
Addresses	Shipping Address	Delete	Recertification	Coliseum Medical Center, LLC d/b/a Piedmont 350 Hospital Drive Macon, GA 31217		9/3/2023 10:52 PM
Addresses	Shipping Address	Insert	Recertification		Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 350 Hospital Drive Macon, GA 31217	9/3/2023 10:52 PM
Details	Last Recertification Date	Update	Recertification		9/3/2023 10:52:42 PM	9/3/2023 10:52 PM
Details	Entity Name	Update	Recertification	COLISEUM MEDICAL CENTERS	Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center	9/3/2023 10:52 PM
Details	State	Update		Approved	Active	4/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Neal, Alisha R Chief Financial Officer PMM & PMN Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 4784648140	1/11/2023 7:14 AM
Details	340B ID	Update	New Registration		DSH110164	1/11/2023 7:14 AM
Dates	Participating Approval Date	Update	New Registration		1/11/2023 7:14:32 AM	1/11/2023 7:14 AM
Details	State	Update	New Registration	Pending	Approved	1/11/2023 7:14 AM
Dates	Signed By Date	Update	New Registration		1/10/2023 8:27:05 AM	1/11/2023 7:14 AM
Dates	Start Date	Update	New Registration		4/1/2023 12:00:00 AM	1/11/2023 7:14 AM
Addresses	Main Address	Insert	New Registration		350 HOSPITAL DRIVE MACON, GA 31203	1/9/2023 1:01 PM
Addresses	Billing Address	Insert	New Registration		Coliseum Medical Center, LLC d/b/a Piedmont 350 Hospital Drive Macon, GA 31217	1/9/2023 1:01 PM
Addresses	Shipping Address	Insert	New Registration		Coliseum Medical Center, LLC d/b/a Piedmont 350 Hospital Drive Macon, GA 31217	1/9/2023 1:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/9/2023 1:01 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000000459A	1/9/2023 1:01 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	1/9/2023 1:01 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1598719643	1/9/2023 1:01 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	1/9/2023 1:01 PM
Contacts	Primary Contact	Insert	New Registration		Stapleton, Cheryl Director of Pharmacy Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 4787654818	1/9/2023 1:01 PM
Contacts	Authorizing Official	Insert	New Registration		Neal, Alisha R Chief Financial Officer PMM & PMN Coliseum Medical Center, LLC d/b/a Piedmont Macon Medical Center 4784648140	1/9/2023 1:01 PM
Details	Assistance Received From Date	Insert	New Registration			1/9/2023 1:01 PM
Details	Assistance Received To Date	Insert	New Registration			1/9/2023 1:01 PM
Details	Last Recertification Date	Insert	New Registration			1/9/2023 1:01 PM
Details	Grant Number	Insert	New Registration			1/9/2023 1:01 PM
Details	340B ID	Insert	New Registration			1/9/2023 1:01 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/9/2023 1:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/9/2023 1:01 PM
Details	Medicare Provider Number	Insert	New Registration		110164	1/9/2023 1:01 PM
Details	Entity Name	Insert	New Registration		COLISEUM MEDICAL CENTERS	1/9/2023 1:01 PM
Details	NOFO Number	Insert	New Registration			1/9/2023 1:01 PM
Details	Program Code	Insert	New Registration		DSH	1/9/2023 1:01 PM
Details	Entity Subname	Insert	New Registration			1/9/2023 1:01 PM
Dates	Participating Approval Date	Insert	New Registration			1/9/2023 1:01 PM
Details	State	Insert	New Registration		Pending	1/9/2023 1:01 PM
Dates	Registration Date	Insert	New Registration		1/9/2023 1:01:54 PM	1/9/2023 1:01 PM
Dates	Signed By Date	Insert	New Registration			1/9/2023 1:01 PM
Dates	Start Date	Insert	New Registration			1/9/2023 1:01 PM
Terminations	Termination Comments	Insert	New Registration			1/9/2023 1:01 PM
Terminations	Termination Date	Insert	New Registration			1/9/2023 1:01 PM
Terminations	Termination Effective Date	Insert	New Registration			1/9/2023 1:01 PM
Terminations	Termination Reason	Insert	New Registration			1/9/2023 1:01 PM