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CVS CAREMARK
CAH451375-00 Liberty Dayton Regional Medical Center
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Covered Entity Details
Entity Name
Liberty Dayton Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451375-00
Entity Address
1353 N.Travis St.
Liberty, TX 77575
Medicare Provider Number
451375
Participating Start Date
7/1/2012
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CVS CAREMARK
Pharmacy Address
DBA CVS/CAREMARK OR CF# 11506
1 GREAT VALLEY BOULEVARD
WILKES BARRE, PA 18706
Pharmacy Comments
Contract Details
Approval Date
7/11/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rhonda Campbell, CEO
(936) 336-7316
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/11/2023
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