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KROGER PHARMACY #621
DSH110018 PIEDMONT NEWTON HOSPITAL, INC.
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Covered Entity Details
Entity Name
PIEDMONT NEWTON HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110018
Entity Address
5126 HOSPITAL DRIVE
COVINGTON, GA 30014
Medicare Provider Number
110018
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #621
Pharmacy Address
3700 SALEM ROAD
COVINGTON, GA 30016
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
4/9/2023
Business decision by covered entity and/or pharmacy
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
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