Contract Pharmacy Details

WALNUT GROVE PLAZA PHARMACY #2
RRC250100-00 BAPTIST MEM HOSPITAL GOLDEN TRIANGLE

Covered Entity Details

Entity Name

BAPTIST MEM HOSPITAL GOLDEN TRIANGLE

Subdivision Name

Type

Rural Referral Center

340B ID

RRC250100-00

Entity Address

2520 FIFTH STREET NORTH
COLUMBUS, MS 39701

Medicare Provider Number

250100

Participating Start Date

4/1/2022

Last Recertification Date

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

WALNUT GROVE PLAZA PHARMACY #2

Pharmacy Address

6027 WALNUT GROVE RD
STE 110
MEMPHIS, TN 38120-2115

Pharmacy Comments

Contract Details

Approval Date

2/1/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Kimberly Young, Vice President-Finance Operations
(901) 227-4080

Contract Pharmacy Representative

Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144

Signed By Date

1/13/2022

340B Drug Pricing Program Database