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PUBLIX PHARMACY #0451
DSH110074 PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC
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Covered Entity Details
Entity Name
PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110074
Entity Address
1199 PRINCE AVENUE
ATHENS, GA 30606
Medicare Provider Number
110074
Participating Start Date
9/29/2005
Last Recertification Date
8/26/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #0451
Pharmacy Address
ATHENS POINTE SHOPPING CENTER
3620 ATLANTA HIGHWAY
ATHENS, GA 30606
Pharmacy Comments
Contract Details
Approval Date
4/7/2020
Contract Begin Date
4/7/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/16/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jason Grady Smith, COO
(706) 475-1860
Contract Pharmacy Representative
Publix
Kimberly Bone, Manager of Managed Care, Pharmacy Operations
(863) 688-1188 Ext: 52364
Signed By Date
4/7/2020
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