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WAL-MART PHARMACY 10-5363
CH040400 Southside Medical Center, Inc.
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Covered Entity Details
Entity Name
Southside Medical Center, Inc.
Subdivision Name
SOUTHSIDE MEDICAL CENTER - Main Center / Corporate HQ
Type
HRSA-Funded Health Center
340B ID
CH040400
Entity Address
1046 Ridge Ave SW
Atlanta, GA 30315-1640
Grant Number
H80CS00576
Participating Start Date
12/1/1992
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5363
Pharmacy Address
11465 TARA BLVD
LOVEJOY, GA 30250
Pharmacy Comments
Contract Details
Approval Date
1/22/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID M. WILLIAMS, CEO
(404) 564-7030
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/22/2014
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