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CVS PHARMACY, INC.
CAH451375-00 Liberty Dayton Regional Medical Center
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Covered Entity Details
Entity Name
Liberty Dayton Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451375-00
Entity Address
1353 N.Travis St.
Liberty, TX 77575
Medicare Provider Number
451375
Participating Start Date
7/1/2012
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 07441
2005 HIGHWAY 90
LIBERTY, TX 77575
Pharmacy Comments
Contract Details
Approval Date
10/19/2012
Contract Begin Date
10/19/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jim Koulovatos, CEO
(936) 336-7316 Ext: 149
Contract Pharmacy Representative
CVS
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
9/17/2012
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