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CITY PHARMACY OF ZEBULON, PC
SCH110002-00 Upson County Hospital, Inc.
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Covered Entity Details
Entity Name
Upson County Hospital, Inc.
Subdivision Name
DBA Upson Regional Medical Center
Type
Sole Community Hospital
340B ID
SCH110002-00
Entity Address
801 West Gordon Street
Thomaston, GA 30286
Medicare Provider Number
110002
Participating Start Date
10/1/2013
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
CITY PHARMACY OF ZEBULON, PC
Pharmacy Address
460 THOMASTON ST
GASKINS KENNETH DAVID - PIC
ZEBULON, GA 30295-3387
Pharmacy Comments
Contract Details
Approval Date
4/2/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John H Williams, CFO/COO
(706) 647-8111 Ext: 1117
Contract Pharmacy Representative
Kenneth Gaskins, Owner
(770) 567-8844
Signed By Date
4/2/2015
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