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KROGER DRUGSTORE #459
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
KROGER DRUGSTORE #459
Pharmacy Address
2875 NORTH DECATUR ROAD
DECATUR, GA 30033
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/12/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Marty Wynn, CFO
(770) 736-2420
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/12/2019
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