Contract Pharmacy Details

WALGREENS SPECIALTY PHARMACY, LLC
DSH110225 PIEDMONT MOUNTAINSIDE HOSPITAL INC.

Covered Entity Details

Entity Name

PIEDMONT MOUNTAINSIDE HOSPITAL INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110225

Entity Address

1266 HIGHWAY 515 SOUTH
JASPER, GA 30143

Medicare Provider Number

110225

Participating Start Date

4/1/2014

Last Recertification Date

8/22/2018

Entity Termination Date

1/1/2019

Pharmacy Details

Pharmacy Name

WALGREENS SPECIALTY PHARMACY, LLC

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188

Pharmacy Comments

Contract Details

Approval Date

7/15/2015

Contract Begin Date

10/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/30/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Frank Powell, CFO
(706) 301-5381

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/15/2015

340B Drug Pricing Program Database