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KROGER PHARMACY #638
DSH110074 PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC
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Covered Entity Details
Entity Name
PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110074
Entity Address
1199 PRINCE AVENUE
ATHENS, GA 30606
Medicare Provider Number
110074
Participating Start Date
9/29/2005
Last Recertification Date
8/26/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #638
Pharmacy Address
1685 OLD PENDERGRASS ROAD
JEFFERSON, GA 30549
Pharmacy Comments
Contract Details
Approval Date
7/10/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/18/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jason Grady Smith, COO
(706) 475-1860
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/10/2019
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