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GEORGIA CVS PHARMACY, L.L.C.
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01586
3001 RICHARD B. RUSSELL PARKWAY
WARNER ROBINS, GA 31088
Pharmacy Comments
Contract Details
Approval Date
7/14/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thomas C Crawford, Chief Operating Officer
(843) 792-8775
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/14/2022
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