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GEORGIA CVS PHARMACY, L.L.C.
DSH110044 PHOEBE SUMTER MEDICAL CENTER
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Covered Entity Details
Entity Name
PHOEBE SUMTER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110044
Entity Address
126 Hwy 280 West
AMERICUS, GA 31719
Medicare Provider Number
110044
Participating Start Date
7/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 2593
1193 US HIGHWAY 19 SOUTH
LEESBURG, GA 31763
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brandi Lee Lunneborg, Chief Executive Officer
(229) 931-1191
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/14/2020
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