Contract Pharmacy Details

GEORGIA CVS PHARMACY, L.L.C.
DSH110034 AU Medical Center, Inc.

Covered Entity Details

Entity Name

AU Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110034

Entity Address

1120 15TH ST.
AUGUSTA, GA 30912

Medicare Provider Number

110034

Participating Start Date

12/1/1992

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

GEORGIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04765
4080 BLOOMFIELD RD.
MACON, GA 31206

Pharmacy Comments

Contract Details

Approval Date

7/14/2021

Contract Begin Date

10/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Allen R Butcher, CFO
(706) 721-3929

Contract Pharmacy Representative

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

Signed By Date

7/14/2021

340B Drug Pricing Program Database