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CYSTIC FIBROSIS SERVICES, LLC
DSH110011 TANNER MEDICAL CENTER
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Covered Entity Details
Entity Name
TANNER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110011
Entity Address
705 DIXIE STREET
CARROLLTON, GA 30117
Medicare Provider Number
110011
Participating Start Date
7/1/2024
Last Recertification Date
8/29/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
5/6/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
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
4/15/2024
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