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ACCREDO HEALTH GROUP INC
DSH340047AA NORTH CAROLINA BAPTIST HOSPITAL
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Covered Entity Details
Entity Name
NORTH CAROLINA BAPTIST HOSPITAL
Subdivision Name
Travel PBC
Type
Disproportionate Share Hospital
340B ID
DSH340047AA
Entity Address
2311 Lewisville-Clemmons Rd
Clemmons, NC 27012
Medicare Provider Number
340047
Outpatient Facility Provider Number
Participating Start Date
10/1/2012
Last Recertification Date
8/16/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
ACCREDO HEALTH GROUP INC
Pharmacy Address
422 GALLIMORE DAIRY RD
SUITE A
GREENSBORO, NC 27409
Pharmacy Comments
Contract Details
Approval Date
4/24/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/16/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Conrad Emmerich, Sr. Vice President,Hospital & Business Services
(336) 716-8941
Contract Pharmacy Representative
NORTH CAROLINA BAPTIST HOSPITAL
Martin Konopko, System Manager 340b
(336) 713-9418
Signed By Date
4/24/2018
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