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OPTION CARE ENTERPRISES, INC.
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
OPTION CARE ENTERPRISES, INC.
Pharmacy Address
OPTION CARE
5854 PEACHTREE CORNERS EAST
SUITE 200
PEACHTREE CORNERS, GA 30092-3410
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
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
Option Care
Derek Bilyk, Program Manager, Health Systems
(224) 813-1283
Signed By Date
10/15/2019
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