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SAMSON MERGER SUB, LLC
CH044369A PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
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Covered Entity Details
Entity Name
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Subdivision Name
Type
HRSA-Funded Health Center
340B ID
CH044369A
Entity Address
360 COLLEGE STREET
BLAKELY, GA 39823
Grant Number
H80CS06454
Participating Start Date
12/6/2005
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
SAMSON MERGER SUB, LLC
Pharmacy Address
HARVEYS SUPERMARKET #1646
12246 COLUMBIA STREET
SUITE F
BLAKELY, GA 39823-2560
Pharmacy Comments
Contract Details
Approval Date
4/7/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Ownership change
Contacts
Covered Entity Signing Official
ANN ADDISON, CEO
(229) 723-2660
Contract Pharmacy Representative
John Fegan, VP of Pharmacy
(904) 783-5000
Signed By Date
4/7/2017
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