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GEORGIA CVS PHARMACY, L.L.C.
SCH110124-00 Wayne Memorial Hospital
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Covered Entity Details
Entity Name
Wayne Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH110124-00
Entity Address
865 South First Street
Jesup, GA 31545
Medicare Provider Number
110124
Participating Start Date
1/1/2012
Last Recertification Date
8/19/2019
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
GEORGIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05684
348 WEST PINE ST.
JESUP, GA 31545
Pharmacy Comments
Contract Details
Approval Date
1/2/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/19/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gregory A. Jones, CFO
(912) 530-3305
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
1/2/2014
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