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DSH110165 Prime Healthcare Foundation - SOUTHERN REGIONAL, LLC dba Southern Regional Medical Center (Active)
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Main Details
Name
Prime Healthcare Foundation - SOUTHERN REGIONAL, LLC dba Southern Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110165
Medicare Provider Number
110165
Additional Details
Current Program Status
Active
Registration Date
4/30/2008
Participating Start Date
10/1/2003
Participating Approval Date
4/30/2008
Last Recertification Date
8/26/2024
Contacts
Authorizing Official
Southern Regional Medical Center
Ela C Lena, President and CEO
(770) 909-2594
Primary Contact
Southern Regional Medical Center
Walter Gerard Lloyd, Director of Pharmacy
(770) 991-8085 Ext: 8085
Addresses
Street Address
11 UPPER RIVERDALE ROAD SW
RIVERDALE, GA 30274-2600
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
June 2025
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