Contract Pharmacy Details

GEORGIA CVS PHARMACY, L.L.C.
DSH110135 R. J. Taylor Memorial Hospital

Covered Entity Details

Entity Name

R. J. Taylor Memorial Hospital

Subdivision Name

DBA Taylor Regional Hospital

Type

Disproportionate Share Hospital

340B ID

DSH110135

Entity Address

222 Perry Highway
Hawkinsville, GA 31036

Medicare Provider Number

110135

Participating Start Date

3/15/2022

Last Recertification Date

9/7/2022

Entity Termination Date

10/1/2023

Pharmacy Details

Pharmacy Name

GEORGIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04267
214 EAST 16TH AVE.
CORDELE, GA 31015

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

9/1/2021
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Jon Green, CEO
(205) 965-1950

Contract Pharmacy Representative

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

Signed By Date

4/13/2020

340B Drug Pricing Program Database