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WAL-MART PHARMACY 10-1070
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
WAL-MART PHARMACY 10-1070
Pharmacy Address
88 HIGHLAND CROSSING
EAST ELLIJAY, GA 30540
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
4/12/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Justin David Leal, COO
(404) 605-2424
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/14/2017
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