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AFFILIATED HEALTH SERVICES, INC.
CAH441300-00 HICKMAN COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
HICKMAN COMMUNITY HOSPITAL
Subdivision Name
DBA SAINT THOMAS HICKMAN HOSPITAL
Type
Critical Access Hospital
340B ID
CAH441300-00
Entity Address
135 EAST SWAN STREET
CENTERVILLE, TN 37033
Medicare Provider Number
441300
Participating Start Date
1/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
AFFILIATED HEALTH SERVICES, INC.
Pharmacy Address
DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/24/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Davis, Saint Thomas Health/Nashville/CEO
(615) 284-6845
Contract Pharmacy Representative
Ascension Michigan Pharmacy
Deborah Sopo, Pharmacy Manager
(248) 865-3770
Signed By Date
7/12/2021
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