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THE KROGER DRUGSTORE #488
CH040400 Southside Medical Center, Inc.
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Covered Entity Details
Entity Name
Southside Medical Center, Inc.
Subdivision Name
SOUTHSIDE MEDICAL CENTER - Main Center / Corporate HQ
Type
HRSA-Funded Health Center
340B ID
CH040400
Entity Address
1046 Ridge Ave SW
Atlanta, GA 30315-1640
Grant Number
H80CS00576
Participating Start Date
12/1/1992
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
THE KROGER DRUGSTORE #488
Pharmacy Address
1160 MORELAND AVENUE
ATLANTA, GA 30316
Pharmacy Comments
Contract Details
Approval Date
4/15/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DAVID M. WILLIAMS, CEO
(404) 564-7030
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/15/2013
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