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CORAM ALTERNATE SITE SERVICES, INC.
DSH110046 PIEDMONT WALTON HOSPITAL, INC.
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Covered Entity Details
Entity Name
PIEDMONT WALTON HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110046
Entity Address
2151 WEST SPRING STREET
MONROE, GA 30655
Medicare Provider Number
110046
Participating Start Date
4/1/2019
Last Recertification Date
8/23/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
CORAM CVS/SPECIALTY INFUSION SERVICES
2140 NEWMARKET PARKWAY
SUITE 106
MARIETTA, GA 30067-8767
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
1/1/2022
Covered Entity Terminated
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
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