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THE PHARMACY AT EMORY
DSH110076 DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL
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Covered Entity Details
Entity Name
DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110076
Entity Address
2701 NORTH DECATUR ROAD
DECATUR, GA 30033
Medicare Provider Number
110076
Participating Start Date
4/1/2002
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
THE PHARMACY AT EMORY
Pharmacy Address
1750 GAMBRELL DR NE STE T203
ATLANTA, GA 30322-1021
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa Urbistondo, Vice President & CFO
(404) 501-5025
Contract Pharmacy Representative
Emory Healthcare
Ryan Haumschild, VP, Ambulatory Pharmacy Ops
(404) 778-2542
Signed By Date
7/11/2024
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