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WALGREEN CO.
DSH110165 Prime Healthcare Foundation - SOUTHERN REGIONAL, LLC dba Southern Regional Medical Center
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Covered Entity Details
Entity Name
Prime Healthcare Foundation - SOUTHERN REGIONAL, LLC dba Southern Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110165
Entity Address
11 UPPER RIVERDALE ROAD SW
RIVERDALE, GA 30274-2600
Medicare Provider Number
110165
Participating Start Date
10/1/2003
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09271
7935 TARA BLVD
JONESBORO, GA 30236-2205
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charlotte W Dupre, President and CEO
(770) 991-8160
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/17/2018
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