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WAL-MART PHARMACY #10-6998
CH04040E SOUTHSIDE MEDICAL CENTER, INC.
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Covered Entity Details
Entity Name
SOUTHSIDE MEDICAL CENTER, INC.
Subdivision Name
SOUTHSIDE MEDICAL CENTER - East Point Clinic
Type
HRSA-Funded Health Center
340B ID
CH04040E
Entity Address
1100 Cleveland Ave
Atlanta, GA 30344-3602
Grant Number
H80CS00576
Participating Start Date
7/1/2016
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY #10-6998
Pharmacy Address
844 CLEVELAND AVENUE
EAST POINT, GA 30344
Pharmacy Comments
Contract Details
Approval Date
1/11/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Claudio Azzariti, CFO
(404) 564-7009
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/11/2018
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