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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
1657 E STONE DR
STE A
KINGSPORT, TN 37660-4669
Pharmacy Comments
Contract Details
Approval Date
4/12/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shane Hilton, VP/CFO - Market Operations
(423) 302-3467
Contract Pharmacy Representative
Steve Kilgore, Svp, President/ceo, Brmmc
(423) 915-5185
Signed By Date
4/12/2016
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