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INGLES MARKETS PHARMACY #409
CH04211P GEORGIA MOUNTAINS HEALTH SERVICES, INC.
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Covered Entity Details
Entity Name
GEORGIA MOUNTAINS HEALTH SERVICES, INC.
Subdivision Name
Fannin County Medical and Admin consolidated site
Type
HRSA-Funded Health Center
340B ID
CH04211P
Entity Address
165 Blue Ridge Overlook
Blue Ridge, GA 30513-4431
Grant Number
H80CS00093
Participating Start Date
4/1/2014
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
INGLES MARKETS PHARMACY #409
Pharmacy Address
100 OLD ORCHARD SQUARE
ELLIJAY, GA 30540
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/29/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven Miracle, CEO
(706) 946-5610
Contract Pharmacy Representative
Georgia Mtns Health
Randy Westbrook, CFO
(706) 946-5609
Signed By Date
10/15/2018
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