Contract Pharmacy Details

HOLIDAY CVS, L.L.C.
DSH010099 D W MCMILLAN MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

D W MCMILLAN MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH010099

Entity Address

1301 BELLEVILLE AVENUE
BREWTON, AL 36427

Medicare Provider Number

010099

Participating Start Date

11/15/2022

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

HOLIDAY CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04027
8361 N CENTURY BLVD
CENTURY, FL 32535

Pharmacy Comments

Contract Details

Approval Date

7/8/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/30/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Chris B. Griffin, Administrator
(251) 867-8061

Contract Pharmacy Representative

CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241

Signed By Date

7/8/2014

340B Drug Pricing Program Database