Covered Entity Details

RRC440012-00 BRISTOL REGIONAL MEDICAL CENTER (Active) - information as of 5/2/2025 10:24:20 PM

Main Details

Name

BRISTOL REGIONAL MEDICAL CENTER

Subdivision Name

Type

Rural Referral Center

Rural

Yes

340B ID

RRC440012-00

Medicare Provider Number

440012

Additional Details

Current Program Status

Active

Registration Date

4/14/2022

Participating Start Date

7/1/2022

Participating Approval Date

5/3/2022

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Ballad Health
Shane Hilton, EVP, Chief Financial Officer
(423) 302-3467

Primary Contact

Ballad Health
Trish Tanner, VP, Chief Pharmacy Officer
(423) 302-3532

Addresses

Street Address

1 MEDICAL PARK BLVD
BRISTOL, TN 37620

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
TN	440012	1124058615
VA	1124058615	1124058615

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10330	2340 HWY 394	BLOUNTVILLE	TN	37617	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09459	6740 BRISTOL HWY	PINEY FLATS	TN	37686	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #13979	1 MEDICAL PARK BLVD, STE 106E	BRISTOL	TN	37620	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10192	1388 VOLUNTEER PKWY.	BRISTOL	TN	37620-5700	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05347	2412 W. STATE STREET	BRISTOL	TN	37620	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09046	1560 LEE HWY	BRISTOL	VA	24201	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/13/2022	10/01/2022	10/01/2022
Contract Detail	WILSON PHARMACY	350 BLOUNTVILLE HWY STE 102		BRISTOL	TN	37620	10/20/2022	01/01/2023	01/01/2023
Contract Detail	WILSON PHARMACY	DBA BALLAD HEALTH PHARMACY	523 N STATE OF FRANKLIN RD	JOHNSON CITY	TN	37604	10/20/2022	01/01/2023	01/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/30/2023 3:59:56 PM	9/4/2024 10:11:39 AM	9/4/2024 10:11 AM
Contacts	Authorizing Official	Update	Profile Change Request	Hilton, Shane Sr VP, Market Financial Operations Ballad Health 4233023467	Hilton, Shane EVP, Chief Financial Officer Ballad Health 4233023467	4/25/2024 2:38 PM
Contacts	Signed By	Update	Profile Change Request	Hilton, Shane Sr VP, Market Financial Operations Ballad Health 4233023467	Hilton, Shane EVP, Chief Financial Officer Ballad Health 4233023467	4/25/2024 2:38 PM
Details	Last Recertification Date	Update	Recertification	9/12/2022 12:52:00 PM	8/30/2023 3:59:56 PM	8/30/2023 3:59 PM
Details	Last Recertification Date	Update	Recertification		9/12/2022 12:52:00 PM	9/12/2022 12:52 PM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	5/3/2022 7:56 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1124058615	5/3/2022 7:56 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	5/3/2022 7:56 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124058615	5/3/2022 7:56 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	5/3/2022 7:56 AM
Contacts	Signed By	Insert	New Registration		Hilton, Shane Sr VP, Market Financial Operations Ballad Health 4233023467	5/3/2022 7:56 AM
Details	340B ID	Update	New Registration		RRC440012-00	5/3/2022 7:56 AM
Dates	Participating Approval Date	Update	New Registration		5/3/2022 7:56:04 AM	5/3/2022 7:56 AM
Details	State	Update	New Registration	Pending	Approved	5/3/2022 7:56 AM
Dates	Signed By Date	Update	New Registration		5/2/2022 9:54:39 AM	5/3/2022 7:56 AM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	5/3/2022 7:56 AM
Contacts	Primary Contact	Update	Profile Change Request	Tanner, Trish AVP, Chief Pharmacy Officer Ballad Health 4233023532	Tanner, Trish VP, Chief Pharmacy Officer Ballad Health 4233023532	5/2/2022 9:35 AM
Addresses	Main Address	Insert	New Registration		1 MEDICAL PARK BLVD BRISTOL, TN 37620	4/14/2022 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2022 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		440012	4/14/2022 12:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/14/2022 12:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124058615	4/14/2022 12:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/14/2022 12:23 PM
Contacts	Primary Contact	Insert	New Registration		Tanner, Trish AVP, Chief Pharmacy Officer Ballad Health 4233023532	4/14/2022 12:23 PM
Contacts	Authorizing Official	Insert	New Registration		Hilton, Shane Sr VP, Market Financial Operations Ballad Health 4233023467	4/14/2022 12:23 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2022 12:23 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2022 12:23 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2022 12:23 PM
Details	Grant Number	Insert	New Registration			4/14/2022 12:23 PM
Details	340B ID	Insert	New Registration			4/14/2022 12:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2022 12:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2022 12:23 PM
Details	Medicare Provider Number	Insert	New Registration		440012	4/14/2022 12:23 PM
Details	Entity Name	Insert	New Registration		BRISTOL REGIONAL MEDICAL CENTER	4/14/2022 12:23 PM
Details	NOFO Number	Insert	New Registration			4/14/2022 12:23 PM
Details	Program Code	Insert	New Registration		RRC	4/14/2022 12:23 PM
Details	Entity Subname	Insert	New Registration			4/14/2022 12:23 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2022 12:23 PM
Details	State	Insert	New Registration		Pending	4/14/2022 12:23 PM
Dates	Registration Date	Insert	New Registration		4/14/2022 12:23:50 PM	4/14/2022 12:23 PM
Dates	Signed By Date	Insert	New Registration			4/14/2022 12:23 PM
Dates	Start Date	Insert	New Registration			4/14/2022 12:23 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2022 12:23 PM
Terminations	Termination Date	Insert	New Registration			4/14/2022 12:23 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2022 12:23 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2022 12:23 PM