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WALGREEN CO.
DSH110046 PIEDMONT WALTON HOSPITAL, INC.
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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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11539
319 S BROAD STREET
MONROE, GA 30655-2119
Pharmacy Comments
Contract Details
Approval Date
7/16/2019
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
Walgreens
Karl Meehan, Vice President,
(847) 315-2663
Signed By Date
7/16/2019
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