Contract Pharmacy Details

ATHENS CREEKSIDE DRUGS
DSH010079 ATHENS-LIMESTONE

Covered Entity Details

Entity Name

ATHENS-LIMESTONE

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH010079

Entity Address

700 WEST MARKET STREET
ATHENS, AL 35611

Medicare Provider Number

010079

Participating Start Date

3/15/2022

Last Recertification Date

9/8/2023

Entity Termination Date

1/1/2024

Pharmacy Details

Pharmacy Name

ATHENS CREEKSIDE DRUGS

Pharmacy Address

JACKSON MARK K
605 HWY 31 SOUTH
SUITE D
ATHENS, AL 35611

Pharmacy Comments

Contract Details

Approval Date

7/2/2010

Contract Begin Date

7/2/2010

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/8/2016
Agreement registered in error

Contacts

Covered Entity Signing Official

KELLI POWERS, CEO
(256) 233-9118

Contract Pharmacy Representative

MARK K. JACKSON, OWNER
(256) 232-8274

Signed By Date

6/21/2010