Contract Pharmacy Details

SOUTHSIDE INFUSION
CH047430 GEORGIA HIGHLANDS MEDICAL SERVICES, INC.

Covered Entity Details

Entity Name

GEORGIA HIGHLANDS MEDICAL SERVICES, INC.

Subdivision Name

GHMS Cumming Family Health Center

Type

HRSA-Funded Health Center

340B ID

CH047430

Entity Address

260 Elm St
Cumming, GA 30040-2467

Grant Number

H80CS00470

Participating Start Date

1/1/2005

Last Recertification Date

2/12/2025

Pharmacy Details

Pharmacy Name

SOUTHSIDE INFUSION

Pharmacy Address

7700 MAIN ST STE 210
HOUSTON, TX 77030-4457

Pharmacy Comments

Contract Details

Approval Date

1/15/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/28/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Todd Shifflet, CEO
(770) 887-1668 Ext: 1102

Contract Pharmacy Representative

Southside Pharmacy
Roshan Koppuzhayil, Director of Pharmacy Operations
(832) 495-5597

Signed By Date

1/15/2020

340B Drug Pricing Program Database