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SCH110100-00 JEFFERSON HOSPITAL (Active)
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Main Details
Name
JEFFERSON HOSPITAL
Subdivision Name
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH110100-00
Medicare Provider Number
110100
Additional Details
Current Program Status
Active
Registration Date
4/8/2019
Participating Start Date
7/1/2019
Participating Approval Date
4/12/2019
Last Recertification Date
8/21/2024
Contacts
Authorizing Official
Jefferson Hospital
James Harrison, CFO
(478) 625-7000 Ext: 1207
Primary Contact
Jefferson Hospital
Wendy Davis, Director of Pharmacy
(478) 625-7000 Ext: 1226
Addresses
Street Address
1067 PEACHTREE STREET
LOUISVILLE, GA 30434-1558
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating start date 4/1/2017; Terminated 7/1/2017; Reinstatement 7/1/2019.
04/10/2019
April 2025
April 2025
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