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WELLSTAR NORTH FULTON HOSPITAL
DSH110143 COBB HOSPITAL, INC.
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Covered Entity Details
Entity Name
COBB HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110143
Entity Address
3950 AUSTELL ROAD
AUSTELL, GA 30106
Medicare Provider Number
110143
Participating Start Date
10/1/2004
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WELLSTAR NORTH FULTON HOSPITAL
Pharmacy Address
3000 HOSPITAL BLVD
ROSWELL, GA 30076
Pharmacy Comments
Contract Details
Approval Date
10/9/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Heath Austin King, CFO
(470) 732-5039
Contract Pharmacy Representative
WellStar Health System
Snehal Doshi, SVP Ancillary and Support Svcs
(470) 644-0322
Signed By Date
10/9/2019
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