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WAL-MART PHARMACY 10-5363
DSH110191 PIEDMONT HENRY HOSPITAL INC.
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Covered Entity Details
Entity Name
PIEDMONT HENRY HOSPITAL INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110191
Entity Address
1133 EAGLES LANDING PARKWAY
STOCKBRIDGE, GA 30281
Medicare Provider Number
110191
Participating Start Date
4/1/2023
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5363
Pharmacy Address
11465 TARA BLVD
LOVEJOY, GA 30250
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/23/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Wesley James, CFO
(678) 604-1001
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/14/2017
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