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WALGREEN CO.
DSH110015 TANNER MEDICAL CENTER/VILLA RICA
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Covered Entity Details
Entity Name
TANNER MEDICAL CENTER/VILLA RICA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110015
Entity Address
601 DALLAS ROAD
VILLA RICA, GA 30180
Medicare Provider Number
110015
Participating Start Date
7/1/2005
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WIGGINS FAMILY PHARMACY
1128 S PARK ST
CARROLLTON, GA 30117
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/21/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carol S. Crews, CFO
(770) 812-9745
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2022
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