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MAIN STREET DRUG LLC
CAH441303-00 THREE RIVERS HOSPITAL
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Covered Entity Details
Entity Name
THREE RIVERS HOSPITAL
Subdivision Name
Three Rivers Hospital
Type
Critical Access Hospital
340B ID
CAH441303-00
Entity Address
451 HWY 13 S
WAVERLY, TN 37185
Medicare Provider Number
441303
Participating Start Date
1/1/2021
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MAIN STREET DRUG LLC
Pharmacy Address
211 WEST MAIN STREET
PO BOX 82
WAVERLY, TN 37185
Pharmacy Comments
Contract Details
Approval Date
10/28/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/20/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Freda B. Russell, CEO/CNO
(931) 296-4203 Ext: 1100
Contract Pharmacy Representative
Main Street Drug
Linda Leonard, Pharmacist
(931) 296-3703
Signed By Date
10/15/2020
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