Contract Pharmacy Details

KROGER PHARMACY #679
DSH110046 PIEDMONT WALTON HOSPITAL, INC.

Covered Entity Details

Entity Name

PIEDMONT WALTON HOSPITAL, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110046

Entity Address

2151 WEST SPRING STREET
MONROE, GA 30655

Medicare Provider Number

110046

Participating Start Date

4/1/2019

Last Recertification Date

8/23/2021

Entity Termination Date

1/1/2022

Pharmacy Details

Pharmacy Name

KROGER PHARMACY #679

Pharmacy Address

4753 ATLANTA HIGHWAY
LOGANVILLE, GA 30052

Pharmacy Comments

Contract Details

Approval Date

7/11/2019

Contract Begin Date

10/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

John G. Miles, Vice President / CFO
(770) 400-2336

Contract Pharmacy Representative

Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875

Signed By Date

7/11/2019

340B Drug Pricing Program Database