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GEORGIA CVS PHARMACY, L.L.C.
DSH110095 TIFT REGIONAL HEALTH SYSTEM, INC
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Covered Entity Details
Entity Name
TIFT REGIONAL HEALTH SYSTEM, INC
Subdivision Name
DBA TIFT REGIONAL MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH110095
Entity Address
901 E. 18TH ST.
TIFTON, GA 31794
Medicare Provider Number
110095
Participating Start Date
7/1/2004
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04203
1027 S. MAIN ST.
MOULTRIE, GA 31768
Pharmacy Comments
Contract Details
Approval Date
10/14/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Troy Buren Brooks, SVP/CFO
(229) 353-3397
Contract Pharmacy Representative
CVS Health
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
10/14/2023
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