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SAMSON MERGER SUB, 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
SAMSON MERGER SUB, LLC
Pharmacy Address
HARVEYS SUPERMARKET #1646
12246 COLUMBIA STREET
SUITE F
BLAKELY, GA 39823-2560
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ginger Cushing, HOSPITAL CEO
(229) 724-4211
Contract Pharmacy Representative
SE Grocers
Scott Wink, Director, Pharmacy Managed Care
(904) 370-7776
Signed By Date
10/17/2016
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