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PPG STORE 3, LLC
DSH040007 ST VINCENT INFIRMARY
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Covered Entity Details
Entity Name
ST VINCENT INFIRMARY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040007
Entity Address
#2 ST. VINCENT CIRCLE
ATTN: PHARMACY
LITTLE ROCK, AR 72205
Medicare Provider Number
040007
Participating Start Date
7/1/2003
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
PPG STORE 3, LLC
Pharmacy Address
DBA HEARTLAND PHARMACY MARKHAM
11414 W MARKHAM ST
SUITE D
LITTLE ROCK, AR 72211
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shawn Barnett, Market SVP-COO-CFO
(501) 552-3571
Contract Pharmacy Representative
Heartland Pharmacy
Clint S Boone, Pharmacist Co-owner
(501) 904-4299
Signed By Date
10/11/2019
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