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PPG STORE 6, LLC
DSH040154 BHMC-CONWAY
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Covered Entity Details
Entity Name
BHMC-CONWAY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040154
Entity Address
1555 EXCHANGE AVENUE
CONWAY, AR 72032
Medicare Provider Number
040154
Participating Start Date
10/1/2020
Last Recertification Date
9/12/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
PPG STORE 6, LLC
Pharmacy Address
DBA: HEARTLAND PHARMACY CONWAY
2235 DAVE WARD DR STE 108
DBA HEARTLAND PHARMACY CONWAY
CONWAY, AR 72034-7040
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
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
7/15/2022
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