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GEORGIA CVS PHARMACY, L.L.C.
DSH110092 DODGE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
DODGE COUNTY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110092
Entity Address
901 GRIFFIN AVE
EASTMAN, GA 31023
Medicare Provider Number
110092
Participating Start Date
7/1/2006
Last Recertification Date
8/31/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 07200
202 N.E. DYKES ST.
COCHRAN, GA 31014
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jimmy LaDon Toole, CEO
(229) 403-9175
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2020
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