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WILSON PHARMACY
RRC440017-02 HOLSTON VALLEY HOSP & MED CTR
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Covered Entity Details
Entity Name
HOLSTON VALLEY HOSP & MED CTR
Subdivision Name
Comprehensive Breast Center / Radiology Breast Center
Type
Rural Referral Center
340B ID
RRC440017-02
Entity Address
103 W. Stone Drive
Kingpsport, TN 37660
Medicare Provider Number
440017
Outpatient Facility Provider Number
Participating Start Date
7/1/2015
Last Recertification Date
8/18/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
WILSON PHARMACY
Pharmacy Address
DBA BALLAD HEALTH PHARMACY
1657 E STONE DR
STE A
KINGSPORT, TN 37660-4669
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Shane Hilton, EVP, Chief Financial Officer
(423) 302-3467
Contract Pharmacy Representative
Balad Health
Steve Kilgore, SVP, Retail and Physician Services
(423) 915-5185
Signed By Date
1/15/2019
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