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CUSTOM PRESCRIPTION SHOPPE
TB309096 AUGUSTA DISTRICT 6
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Covered Entity Details
Entity Name
AUGUSTA DISTRICT 6
Subdivision Name
EAST CENTRAL HEALTH DISTRICT
Type
Tuberculosis
340B ID
TB309096
Entity Address
1914 NORTH LEG ROAD
BLDG K
AUGUSTA, GA 30909-4437
Grant Number
5 NU52PS004666-05-00
Participating Start Date
1/1/1997
Last Recertification Date
5/29/2019
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
CUSTOM PRESCRIPTION SHOPPE
Pharmacy Address
CAROLYN HOLGATE
1543 15TH STREET
AUGUSTA, GA 30901-3090
Pharmacy Comments
Contract Details
Approval Date
10/14/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
ROSE-MARIE F SALES, DIRECTOR, TUBERCULOSIS PROGRAM
(404) 657-2597
Contract Pharmacy Representative
Eric Holgate, Pharmacist
(706) 737-0500
Signed By Date
10/14/2016
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