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GEORGIA CVS PHARMACY, L.L.C.
CAH111314-00 LIFEBRITE COMMUNITY HOSPITAL OF EARL
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Covered Entity Details
Entity Name
LIFEBRITE COMMUNITY HOSPITAL OF EARL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111314-00
Entity Address
11740 COLUMBIA STREET
BLAKELY, GA 39823
Medicare Provider Number
111314
Participating Start Date
10/1/2023
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05618
11685 COLUMBIA ST.,
BLAKELY, GA 39823
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
1/26/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph S. McNulty III, President
(601) 849-6440
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
7/8/2014
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