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CVS TN DISTRIBUTION, LLC
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
CVS TN DISTRIBUTION, LLC
Pharmacy Address
10017 KINGSTON PIKE
KNOXVILLE, TN 37922
Pharmacy Comments
Contract Details
Approval Date
10/7/2014
Contract Begin Date
1/1/2015
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
ALLEN J. GAMBLE, HOSPITAL CEO
(229) 724-4211
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/7/2014
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