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SHOALS FAMILY PHARMACY GROUP, INC
DSH010158 RUSSELLVILLE HOSPITAL
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Covered Entity Details
Entity Name
RUSSELLVILLE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010158
Entity Address
15155 US-43
RUSSELLVILLE, AL 35653
Medicare Provider Number
010158
Participating Start Date
4/1/2017
Last Recertification Date
8/30/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
SHOALS FAMILY PHARMACY GROUP, INC
Pharmacy Address
DBA FAMILY PHARMACY OF RUSSELLVILLE
455 UNDERWOOD RD
RUSSELLVILLE, AL 35653-0911
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tim Brown, Chief Financial Officer
(865) 888-9359
Contract Pharmacy Representative
Family Pharmacy of Russellville
Jody Kiel, Owner
(256) 332-4021 Ext: 2563325545
Signed By Date
7/17/2018
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