Contract Pharmacy Details

WRENS DRUG
SCH110100-00 JEFFERSON HOSPITAL

Covered Entity Details

Entity Name

JEFFERSON HOSPITAL

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH110100-00

Entity Address

1067 PEACHTREE STREET
LOUISVILLE, GA 30434-1558

Medicare Provider Number

110100

Participating Start Date

7/1/2019

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

WRENS DRUG

Pharmacy Address

206 BROAD STREET
PO BOX 693
WRENS, GA 30833

Pharmacy Comments

Contract Details

Approval Date

7/23/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2015

Contacts

Covered Entity Signing Official

MATT CLARK, CFO/CONTROLLER
(478) 625-7000 Ext: 208

Contract Pharmacy Representative

Michelle McCoy, Pharmacy Manager
(706) 547-2225

Signed By Date

7/23/2014