Contract Pharmacy Details

GEORGIA CVS PHARMACY, L.L.C.
DSH110046 PIEDMONT WALTON HOSPITAL, INC.

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

GEORGIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04730
1187 GRAYSON HWY.
LAWRENCEVILLE, GA 30045

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

340B Drug Pricing Program Database