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GEORGIA CVS PHARMACY, L.L.C.
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
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 07637
5848 HWY 124 WEST
HOSCHTON, GA 30548
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jason Grady Smith, COO
(706) 475-1860
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2020
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