Contract Pharmacy Details

KROGER DRUG STORE #428
DSH110074 PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC

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 DRUG STORE #428

Pharmacy Address

191 ALPS ROAD
ATHENS, GA 30606

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

3/23/2023
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

340B Drug Pricing Program Database