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WALGREEN CO
DSH110164 Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center
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Covered Entity Details
Entity Name
Coliseum Medical Center, Inc. d/b/a Piedmont Macon Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110164
Entity Address
350 Hospital Drive
Macon, GA 31217
Medicare Provider Number
110164
Participating Start Date
4/1/2023
Last Recertification Date
8/14/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #11940
274 W CLINTON ST
GRAY, GA 31032
Pharmacy Comments
Contract Details
Approval Date
4/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alisha R Neal, Chief Financial Officer PMM & PMN
(478) 464-8140
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/7/2023
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