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WILSON PHARMACY
DSH440176 INDIAN PATH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
INDIAN PATH COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440176
Entity Address
2000 BROOKSIDE DRIVE
KINGSPORT, TN 37660-4627
Medicare Provider Number
440176
Participating Start Date
10/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WILSON PHARMACY
Pharmacy Address
DBA BALLAD HEALTH PHARMACY
523 N STATE OF FRANKLIN RD
JOHNSON CITY, TN 37604
Pharmacy Comments
11/16/2012 address update (was 525 N. State of Franklin Rd.)
Contract Details
Approval Date
10/16/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shane Hilton, VP/CFO - Market Operations
(423) 302-3467
Contract Pharmacy Representative
Balad Health
Steve Kilgore, SVP, Retail and Physician Services
(423) 915-5185
Signed By Date
10/16/2020
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