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PALACE DRUG
RRC040027-00 BAXTER REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BAXTER REGIONAL MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC040027-00
Entity Address
624 HOSPITAL DRIVE
MOUNTAIN HOME, AR 72653
Medicare Provider Number
040027
Participating Start Date
1/1/2020
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
PALACE DRUG
Pharmacy Address
270 MAIN ST
MAMMOTH SPRING, AR 72554-7466
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Elizabeth Kay Smith, Pharmacy Operations Coordinator
(870) 508-7369
Contract Pharmacy Representative
Palace Drug
MJ Clark, Pharmacy Director
(870) 625-3222
Signed By Date
10/17/2022
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