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CYSTIC FIBROSIS SERVICES, LLC
DSH110225 PIEDMONT MOUNTAINSIDE HOSPITAL INC.
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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
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
6/29/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Justin David Leal, COO
(404) 605-2424
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/29/2017
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