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BROOKSHIRE BROTHERS PHARMACY #43
CAH451375-00 Liberty Dayton Regional Medical Center
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Covered Entity Details
Entity Name
Liberty Dayton Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451375-00
Entity Address
1353 N.Travis St.
Liberty, TX 77575
Medicare Provider Number
451375
Participating Start Date
7/1/2012
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
BROOKSHIRE BROTHERS PHARMACY #43
Pharmacy Address
403 EAST HWY 90
DAYTON, TX 77535
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew Thornton, CEO
(936) 336-7316 Ext: 149
Contract Pharmacy Representative
Brookshire Bros.
Ken Breda, Director of Pharmacy
(936) 634-8155 Ext: 4350
Signed By Date
4/13/2020
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