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WAL-MART PHARMACY 10-4558
DSH110018 PIEDMONT NEWTON HOSPITAL, INC.
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Covered Entity Details
Entity Name
PIEDMONT NEWTON HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110018
Entity Address
5126 HOSPITAL DRIVE
COVINGTON, GA 30014
Medicare Provider Number
110018
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4558
Pharmacy Address
4200 SALEM ROAD
COVINGTON, GA 30016
Pharmacy Comments
Contract Details
Approval Date
7/13/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/23/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TROY B. BROOKS, CFO
(770) 385-4426
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/13/2017
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