Contract Pharmacy Details

GEORGIA CVS PHARMACY, L.L.C.
DSH110073 DORMINY MEDICAL CENTER

Covered Entity Details

Entity Name

DORMINY MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110073

Entity Address

200 PERRY HOUSE ROAD
FITZGERALD, GA 31750

Medicare Provider Number

110073

Participating Start Date

9/9/2005

Last Recertification Date

9/7/2023

Entity Termination Date

4/1/2024

Pharmacy Details

Pharmacy Name

GEORGIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04514
111 E. 8TH ST.
TIFTON, GA 31794

Pharmacy Comments

Contract Details

Approval Date

1/15/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/1/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Paige Wynn, COO / CFO
(229) 468-3845

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/15/2020

340B Drug Pricing Program Database