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WALGREEN CO
DSH110091 Piedmont Rockdale Hospital, Inc.
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Covered Entity Details
Entity Name
Piedmont Rockdale Hospital, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110091
Entity Address
1412 Milstead Ave NE
CONYERS, GA 30012
Medicare Provider Number
110091
Participating Start Date
4/1/2019
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #10479
1783 HIGHWAY 138 SE
CONYERS, GA 30013
Pharmacy Comments
Contract Details
Approval Date
1/22/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marty Wynn, CFO
(770) 736-2420
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2019
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