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PPG STORE 7 LLC DBA HEARTLAND PHARMACY A
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 7 LLC DBA HEARTLAND PHARMACY A
Pharmacy Address
102 N 27TH ST
ARKADELPHIA, AR 71923
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/15/2023
Business decision by covered entity and/or pharmacy
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
1/15/2021
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