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VIRGINIA CVS PHARMACY, L.L.C.
DSH490114 LONESOME PINE HOSPITAL
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Covered Entity Details
Entity Name
LONESOME PINE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490114
Entity Address
1990 HOLTON AVENUE EAST
BIG STONE GAP, VA 24219
Medicare Provider Number
490114
Participating Start Date
10/1/2006
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
VIRGINIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03922
1128 PARK AVE., NW
NORTON, VA 24273
Pharmacy Comments
Contract Details
Approval Date
10/13/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alice Pope, EVP and CFO
(423) 230-8209
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/13/2014
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