Contract Pharmacy Details

WALGREEN CO
DSH110143 COBB HOSPITAL, INC.

Covered Entity Details

Entity Name

COBB HOSPITAL, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110143

Entity Address

3950 AUSTELL ROAD
AUSTELL, GA 30106

Medicare Provider Number

110143

Participating Start Date

10/1/2004

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO

Pharmacy Address

DBA: WALGREENS #10968
5000 FLOYD ROAD SW
MABLETON, GA 30126

Pharmacy Comments

Contract Details

Approval Date

10/12/2017

Contract Begin Date

1/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/24/2025
Pharmacy closed

Contacts

Covered Entity Signing Official

DAROLD ETHERIDGE, CFO
(470) 732-5039

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/12/2017

340B Drug Pricing Program Database