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SAMSON MERGER SUB, LLC
CH044369A PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
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Covered Entity Details
Entity Name
PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Subdivision Name
Type
HRSA-Funded Health Center
340B ID
CH044369A
Entity Address
360 COLLEGE STREET
BLAKELY, GA 39823
Grant Number
H80CS06454
Participating Start Date
12/6/2005
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
SAMSON MERGER SUB, LLC
Pharmacy Address
HARVEYS SUPERMARKET #1666
1207 W SCREVEN STREET
QUITMAN, GA 31643-1817
Pharmacy Comments
Contract Details
Approval Date
1/10/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/2/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
ANN ADDISON, CEO
(229) 723-2660
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
1/10/2018
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