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GEORGIA CVS PHARMACY, L.L.C.
DSH110135 R. J. Taylor Memorial Hospital
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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 # 01374
800 HWY 96
WARNER ROBINS, GA 31088
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2023
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
4/15/2022
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