Contract Pharmacy Details

PRIME THERAPEUTICS SPECIALTY PHARMACY LL
DSH340014 Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center

Covered Entity Details

Entity Name

Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH340014

Entity Address

3333 SILAS CREEK PARKWAY
WINSTON-SALEM, NC 27103-3013

Medicare Provider Number

340014

Participating Start Date

7/1/2007

Last Recertification Date

9/6/2019

Entity Termination Date

7/7/2020

Pharmacy Details

Pharmacy Name

PRIME THERAPEUTICS SPECIALTY PHARMACY LL

Pharmacy Address

ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992

Pharmacy Comments

Contract Details

Approval Date

7/11/2019

Contract Begin Date

10/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/7/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Cedric A Terrell, SVP Pharmacy Services
(704) 384-0611

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/11/2019

340B Drug Pricing Program Database