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COASTAL PHARMACY, INC.
CAH111335-00 LIBERTY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LIBERTY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH111335-00
Entity Address
462 E.G. MILES PARKWAY
HINESVILLE, GA 31313
Medicare Provider Number
111335
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
COASTAL PHARMACY, INC.
Pharmacy Address
D/B/A HINESVILLE PHARMACY
481 ELMA G MILES PKWY
HINESVILLE, GA 31313-4006
Pharmacy Comments
Contract Details
Approval Date
12/15/2011
Contract Begin Date
12/15/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Scott Kroell, CEO
(912) 369-9482
Contract Pharmacy Representative
Al Dixon, Owner
(912) 756-3331
Signed By Date
12/7/2011
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