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WILSON PHARMACY
DSH440063 JOHNSON CITY MEDICAL CENTER
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Covered Entity Details
Entity Name
JOHNSON CITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440063
Entity Address
400 N. STATE OF FRANKLIN RD.
JOHNSON CITY, TN 37604-6094
Medicare Provider Number
440063
Participating Start Date
7/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WILSON PHARMACY
Pharmacy Address
DBA BALLAD HEALTH PHARMACY
1657 E STONE DR
STE A
KINGSPORT, TN 37660-4669
Pharmacy Comments
Contract Details
Approval Date
3/19/2012
Contract Begin Date
3/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/22/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Nicely, CEO
(423) 431-1084
Contract Pharmacy Representative
Steve Kilgore, Svp, President/ceo, Brmmc
(423) 915-5185
Signed By Date
2/28/2012
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