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SWAN PHARMACY, INC.
SCH110100-00 JEFFERSON HOSPITAL
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Covered Entity Details
Entity Name
JEFFERSON HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH110100-00
Entity Address
1067 PEACHTREE STREET
LOUISVILLE, GA 30434-1558
Medicare Provider Number
110100
Participating Start Date
7/1/2019
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SWAN PHARMACY, INC.
Pharmacy Address
PO BOX 69
48 N MAIN ST
WADLEY, GA 30477
Pharmacy Comments
Contract Details
Approval Date
7/2/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Harrison, CFO
(478) 625-7000 Ext: 1207
Contract Pharmacy Representative
Swan Pharmacy
Laura B Swan, Owner
(478) 252-5252
Signed By Date
7/2/2020
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