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TRISTATE INFUSION LLC
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
TRISTATE INFUSION LLC
Pharmacy Address
1211 SE 28TH ST STE 10
BENTONVILLE, AR 72712
Pharmacy Comments
Contract Details
Approval Date
1/9/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/10/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Elizabeth Kay Smith, Pharmacy Operations Coordinator
(870) 508-7369
Contract Pharmacy Representative
Vital Care Infusion Services of NWA
Lori Godfrey, Director of New Business Development
(870) 926-0750
Signed By Date
1/9/2023
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