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FRED'S PHARMACY # 3371
SCH110100-00 JEFFERSON HOSPITAL
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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
FRED'S PHARMACY # 3371
Pharmacy Address
605 NORTH MAIN STREET
WRENS, GA 30833
Pharmacy Comments
Contract Details
Approval Date
10/23/2014
Contract Begin Date
1/1/2015
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
Shannon Strickland, SVP, Pharmacy Development
(901) 238-3113
Signed By Date
10/23/2014
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