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PPG STORE 3, LLC
DSH040114 BAPTIST HEALTH MEDICAL CENTER - LR
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Covered Entity Details
Entity Name
BAPTIST HEALTH MEDICAL CENTER - LR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040114
Entity Address
9601 Baptist Health Drive
LITTLE ROCK, AR 72205
Medicare Provider Number
040114
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
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
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Heartland Pharmacy
Clint S Boone, Pharmacist Co-owner
(501) 904-4299
Signed By Date
4/14/2020
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