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LANGSTON DRUG STORE
DSH040055 Baptist Health - Fort Smith
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Covered Entity Details
Entity Name
Baptist Health - Fort Smith
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040055
Entity Address
1001 TOWSON AVE
FORT SMITH, AR 72901
Medicare Provider Number
040055
Participating Start Date
10/1/2019
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
LANGSTON DRUG STORE
Pharmacy Address
1202 E. MAIN ST.
VAN BUREN, AR 72956-4555
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/5/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Langston Drug Store
Rhonda Miller-Morrison, President
(417) 678-2260
Signed By Date
4/14/2020
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