Contract Pharmacy Details

HARRIS TEETER PHARMACY #0216
DSH340047 NORTH CAROLINA BAPTIST HOSPITAL

Covered Entity Details

Entity Name

NORTH CAROLINA BAPTIST HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH340047

Entity Address

MEDICAL CENTER BOULEVARD
WINSTON-SALEM, NC 27157

Medicare Provider Number

340047

Participating Start Date

4/1/1998

Last Recertification Date

8/23/2024

Pharmacy Details

Pharmacy Name

HARRIS TEETER PHARMACY #0216

Pharmacy Address

2281 CLOVERDALE AVE
WINSTON SALEM, NC 27103

Pharmacy Comments

Contract Details

Approval Date

10/15/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/3/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Conrad Emmerich, Sr. Vice President,Hospital & Business Services
(336) 716-8941

Contract Pharmacy Representative

Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875

Signed By Date

10/15/2020

340B Drug Pricing Program Database