340B Drug Pricing Program Database


CAH451375-00 Liberty Dayton Regional Medical Center (Active) - information as of 6/3/2025 12:02:06 PM

Main Details
Liberty Dayton Regional Medical Center
Critical Access Hospital
No
CAH451375-00
451375


Additional Details
Active
4/26/2012
7/1/2012
5/30/2012
8/27/2024

Contacts

Liberty Dayton Regional Medical Center
Rhonda Campbell, CEO
(936) 336-7316

LIBERTY DAYTON REGIONAL MEDICAL CENTER
Aurora Davison, Pharmacy Director
(936) 336-7316 Ext: 116

Addresses

1353 N.Travis St.
Liberty, TX 77575

Same as Street Address


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Parent/Child
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

No
Shipping Addresses

Same as Street Address
Contract Pharmacies
Contract DetailPharmacy NameAddressAddress Cont.CityStateZip CodeApproval DateBegin DateCarve-In Effective DateTermination DateLast Updated On
Contract DetailBROOKSHIRE BROTHERS PHARMACY #43403 EAST HWY 90
DAYTONTX7753504/13/202007/01/2020 12/31/202303/18/2024
Contract DetailBROOKSHIRE BROTHERS PHARMACY #512325 NORTH MAIN
LIBERTYTX7757504/13/202007/01/2020 12/31/202303/18/2024
Contract DetailCVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870607/11/202310/01/2023  10/01/2023
Contract DetailCVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005607/11/202310/01/2023  10/01/2023
Contract DetailCVS PHARMACY, INC.DBA: CVS/PHARMACY # 07441 2005 HIGHWAY 90
LIBERTYTX7757510/19/201210/19/2012  03/28/2013
Contract DetailCVS PHARMACY, INC.DBA: CVS/PHARMACY # 03699 3505 CENTER ST.
DEER PARKTX7753607/09/202010/01/2020  10/01/2020
Contract DetailCVS PHARMACY, INC.DBA: CVS/PHARMACY # 07432 2110 N FRAZIER
CONROETX7730107/09/202010/01/2020 08/30/202109/17/2021
Contract DetailWAL-MART CENTRAL FILL 10-2670608 SPRING HILL DR # 3 SUITE 300
SPRINGTX7738610/15/201801/01/2019  01/01/2019
Contract DetailWAL-MART PHARMACY 10-11862121 US BYPASS 146
LIBERTYTX7757511/20/201201/01/2013  03/28/2013
Contract DetailWAL-MART PHARMACY 10-53152354 COMMERCE PARK DR.
ORLANDOFL3281910/15/201801/01/2019  01/01/2019
Contract DetailWAL-MART PHARMACY 10-59979600 PARKSOUTH CT. SUITE 100
ORLANDOFL3283710/15/201801/01/2019  01/01/2019
Contract DetailWALMART PHARMACY 10-51692252 NORTH 8TH STREET
SUITE A 		ROGERSAR7275604/13/202307/01/2023  07/01/2023
Contract DetailWalmart Pharmacy 10-76112501 Perry Rd
PlainfieldIN4616810/11/202301/01/2024  01/01/2024
Parent/Child
340B IDHierarchyEntity TypeNameSub NameAddressCityState340B Status
CAH451375-01ChildCAHLiberty Dayton Regional Medical CenterLiberty Dayton Rural Health Clinic - Liberty Dayton Medical Clinic1201 N Travis St.LibertyTXActive
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
DetailsLast Recertification DateUpdateRecertification8/14/2023 10:52:26 AM8/27/2024 2:54:00 PM8/27/2024 2:54 PM
DetailsLast Recertification DateUpdateRecertification9/8/2022 2:54:46 PM8/14/2023 10:52:26 AM8/14/2023 10:52 AM
DetailsLast Recertification DateUpdateRecertification9/2/2021 9:45:49 AM9/8/2022 2:54:46 PM9/8/2022 2:54 PM
ContactsAuthorizing OfficialUpdateProfile Change RequestCampbell, Rhonda COO Liberty Dayton Regional Medical Center 9363367316Campbell, Rhonda CEO Liberty Dayton Regional Medical Center 93633673168/24/2022 2:18 PM
ContactsPrimary ContactUpdateChange RequestPavliska, Amanda K Medical Staff Coordinator Liberty Dayton Regional Medical Center 9363367316-132Davison, Aurora Pharmacy Director LIBERTY DAYTON REGIONAL MEDICAL CENTER 9363367316-1162/22/2022 8:09 AM
DetailsLast Recertification DateUpdateRecertification9/9/2020 7:38:20 AM9/2/2021 9:45:49 AM9/2/2021 9:45 AM
DetailsLast Recertification DateUpdateRecertification8/26/2019 10:33:29 AM9/9/2020 7:38:20 AM9/9/2020 7:38 AM
ContactsAuthorizing OfficialUpdateChange RequestThornton, Matthew CEO Liberty County Hospital District No 1 9363367316-149Campbell, Rhonda COO Liberty Dayton Regional Medical Center 93633673167/9/2020 1:53 PM
DetailsLast Recertification DateUpdateRecertification8/21/2018 5:12:16 PM8/26/2019 10:33:29 AM8/26/2019 10:33 AM
DetailsLast Recertification DateUpdateRecertification12/4/2017 4:34:16 PM8/21/2018 5:12:16 PM8/21/2018 5:12 PM
ContactsPrimary ContactUpdateRecertificationDavison, Aurora Pharmacy Director 9363367316-116Pavliska, Amanda K Medical Staff Coordinator Liberty Dayton Regional Medical Center 9363367316-13212/4/2017 4:34 PM
DetailsLast Recertification DateUpdateRecertification8/31/2016 12:00:00 AM12/4/2017 4:34:16 PM12/4/2017 4:34 PM
ContactsAuthorizing OfficialUpdate Thornton, Matthew CEO 9363367316-149Thornton, Matthew CEO Liberty County Hospital District No 1 9363367316-14911/9/2017 9:45 AM
AddressesMain AddressInsert   1353 N.Travis St. Liberty, TX 775758/31/2016 12:49 PM
ContactsPrimary ContactInsert  Davison, Aurora Pharmacy Director 9363367316-1168/31/2016 12:49 PM
ContactsAuthorizing OfficialUpdate Koulovatos, Jim CEO 9363367316-149Thornton, Matthew CEO 9363367316-1498/31/2016 12:49 PM
ContactsSigned ByInsert  Mason, Ray Interim CEO 9363367316-1498/31/2016 12:49 PM
DetailsLast Recertification DateUpdate 8/6/2015 12:00:00 AM8/31/2016 12:00:00 AM8/31/2016 12:49 PM
ContactsAuthorizing OfficialInsert  Koulovatos, Jim CEO 9363367316-1498/29/2016 11:13 AM
DetailsLast Recertification DateUpdate 8/6/2014 12:00:00 AM8/6/2015 12:00:00 AM8/6/2015 4:03 PM
DetailsLast Recertification DateUpdate 9/3/2013 3:35:56 PM8/6/2014 12:00:00 AM8/6/2014 9:14 AM
DetailsLast Recertification DateUpdate  9/3/2013 3:35:56 PM9/3/2013 3:35 PM
Details340B IDUpdate IS-EMG-CAH451375-00CAH451375-005/30/2012 7:07 PM
DatesParticipating Approval DateUpdate  5/30/2012 12:00:00 AM5/30/2012 7:07 PM
DetailsStateUpdate PendingActive5/30/2012 7:07 PM
DatesStart DateUpdate  7/1/2012 12:00:00 AM5/30/2012 7:07 PM
Details340B IDUpdate EMG-04262012IS-EMG-CAH451375-005/8/2012 2:12 PM
Details340B IDUpdate ONLINE_REGEMG-042620124/26/2012 2:33 PM
DetailsLast Recertification DateInsert   4/26/2012 12:21 PM
DetailsGrant NumberInsert   4/26/2012 12:21 PM
Details340B IDInsert  ONLINE_REG4/26/2012 12:21 PM
DetailsIs Authorizing Official EHB DataInsert   4/26/2012 12:21 PM
DatesLast Date That 340B Drugs PurchasedInsert   4/26/2012 12:21 PM
DetailsMedicare Provider NumberInsert  4513754/26/2012 12:21 PM
DetailsEntity NameInsert  Liberty Dayton Regional Medical Center4/26/2012 12:21 PM
DetailsProgram CodeInsert  CAH4/26/2012 12:21 PM
DetailsEntity SubnameInsert   4/26/2012 12:21 PM
DatesParticipating Approval DateInsert   4/26/2012 12:21 PM
DetailsStateInsert  Pending4/26/2012 12:21 PM
DatesRegistration DateInsert  4/26/2012 12:00:00 AM4/26/2012 12:21 PM
DatesSigned By DateInsert  4/26/2012 12:00:00 AM4/26/2012 12:21 PM
DatesStart DateInsert   4/26/2012 12:21 PM
TerminationsTermination CommentsInsert   4/26/2012 12:21 PM
TerminationsTermination DateInsert   4/26/2012 12:21 PM
TerminationsTermination Effective DateInsert   4/26/2012 12:21 PM
TerminationsTermination ReasonInsert   4/26/2012 12:21 PM