Contract Pharmacy Details

WALGREEN CO.
DSH110225 PIEDMONT MOUNTAINSIDE HOSPITAL INC.

Covered Entity Details

Entity Name

PIEDMONT MOUNTAINSIDE HOSPITAL INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110225

Entity Address

1266 HIGHWAY 515 SOUTH
JASPER, GA 30143

Medicare Provider Number

110225

Participating Start Date

4/1/2014

Last Recertification Date

8/22/2018

Entity Termination Date

1/1/2019

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

RITE AID #11737
2017 MARIETTA HWY
CANTON, GA 30114

Pharmacy Comments

Contract Details

Approval Date

7/13/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/30/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

John G. Miles, Vice President / CFO
(770) 400-2336

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/13/2018

340B Drug Pricing Program Database