Contract Pharmacy Details

GEORGIA CVS PHARMACY, L.L.C.
DSH110091 Piedmont Rockdale Hospital, Inc.

Covered Entity Details

Entity Name

Piedmont Rockdale Hospital, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110091

Entity Address

1412 Milstead Ave NE
CONYERS, GA 30012

Medicare Provider Number

110091

Participating Start Date

4/1/2019

Last Recertification Date

8/29/2024

Pharmacy Details

Pharmacy Name

GEORGIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08418
10267 HIGHWAY 36
COVINGTON, GA 30014

Pharmacy Comments

Contract Details

Approval Date

7/15/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Marty Wynn, CFO
(770) 736-2420

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/15/2020

340B Drug Pricing Program Database