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WILSON PHARMACY
RRC440017-05 HOLSTON VALLEY HOSP & MED CTR
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Covered Entity Details
Entity Name
HOLSTON VALLEY HOSP & MED CTR
Subdivision Name
Holston Valley Med Center Diagnostics / Cardiovascular JC Stress Testing
Type
Rural Referral Center
340B ID
RRC440017-05
Entity Address
2428 Knob Creek Rd Suite 251
Johnson City, TN 37604
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
523 N STATE OF FRANKLIN RD
JOHNSON CITY, TN 37604
Pharmacy Comments
11/16/2012 address update (was 525 N. State of Franklin Rd.)
Contract Details
Approval Date
1/16/2019
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
1/16/2019
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