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MEDICAL CENTER PHARMACY NT INC
DSH440057 CLAIBORNE MEDICAL CENTER
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Covered Entity Details
Entity Name
CLAIBORNE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440057
Entity Address
1850 OLD KNOXVILLE ROAD
TAZEWELL, TN 37879
Medicare Provider Number
440057
Participating Start Date
7/1/2007
Last Recertification Date
9/4/2014
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
MEDICAL CENTER PHARMACY NT INC
Pharmacy Address
606 NORTH BROAD STREET
PO BOX 297
NEW TAZEWELL, TN 37825
Pharmacy Comments
Contract Details
Approval Date
1/16/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tim S. Brown, CEO
(423) 526-2200
Contract Pharmacy Representative
Derek Hicks, PIC
(423) 626-5411
Signed By Date
1/9/2013
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