Contract Pharmacy Details

ALABAMA CVS PHARMACY, L.L.C.
DSH010125 LAKELAND COMMUNITY HOSPITAL

Covered Entity Details

Entity Name

LAKELAND COMMUNITY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH010125

Entity Address

42024 HIGHWAY 195 EAST
HALEYVILLE, AL 35565

Medicare Provider Number

010125

Participating Start Date

4/1/2020

Last Recertification Date

8/16/2021

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

ALABAMA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04822
1901 11TH AVENUE
HALEYVILLE, AL 35565

Pharmacy Comments

Contract Details

Approval Date

4/15/2020

Contract Begin Date

4/29/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Ashley Pool, Chief Executive Officer
(205) 485-7108

Contract Pharmacy Representative

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

Signed By Date

4/15/2020

340B Drug Pricing Program Database