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OPTION CARE ENTERPRISES, INC.
DSH110225 PIEDMONT MOUNTAINSIDE HOSPITAL INC.
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Covered Entity Details
Entity Name
PIEDMONT MOUNTAINSIDE HOSPITAL INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110225
Entity Address
1266 HIGHWAY 515 SOUTH
JASPER, GA 30143
Medicare Provider Number
110225
Participating Start Date
4/1/2014
Last Recertification Date
8/22/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
OPTION CARE ENTERPRISES, INC.
Pharmacy Address
OPTION CARE
5854 PEACHTREE CORNERS EAST
SUITE 200
PEACHTREE CORNERS, GA 30092-3410
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John G. Miles, Vice President / CFO
(770) 400-2336
Contract Pharmacy Representative
Option Care
Derek Bilyk, Program Manager, Health Systems
(224) 813-1283
Signed By Date
1/15/2018
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