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SAMSON MERGER SUB, LLC
CAH111308-00 CLINCH MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CLINCH MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111308-00
Entity Address
1050 VALDOSTA HIGHWAY
HOMERVILLE, GA 31634
Medicare Provider Number
111308
Participating Start Date
10/1/2018
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
SAMSON MERGER SUB, LLC
Pharmacy Address
HARVEYS SUPERMARKET #1602
207 E MCPHERSON AVE
NASHVILLE, GA 31639-2249
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Angela P Ammons, CEO
(912) 487-5211 Ext: 4348
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
10/14/2019
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