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LOUISVILLE DRUG CO
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
LOUISVILLE DRUG CO
Pharmacy Address
LOUISVILLE DRUG COMPANY
101 E BROAD ST
LOUISVILLE, GA 30434
Pharmacy Comments
Contract Details
Approval Date
1/5/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/10/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Harrison, CFO
(478) 625-7000 Ext: 1207
Contract Pharmacy Representative
Louisville Drug
Gloria Machalk, Pharmacist / Owner
(478) 625-7575
Signed By Date
1/5/2021
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