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TENNESSEE CVS PHARMACY, L.L.C.
DSH440132 West Tennessee Healthcare Henry County Hospital
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Covered Entity Details
Entity Name
West Tennessee Healthcare Henry County Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440132
Entity Address
301 TYSON AVENUE
PARIS, TN 38242
Medicare Provider Number
440132
Participating Start Date
7/1/2020
Last Recertification Date
8/13/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
TENNESSEE CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY # 11071
116 COMMONS DR.
MARTIN, TN 38237
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lisa Puckett Casteel, CEO
(731) 644-8478
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2020
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