Contract Pharmacy Details

RITE AID OF TENNESSEE, INC.
DSH440057 CLAIBORNE MEDICAL CENTER

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

RITE AID OF TENNESSEE, INC.

Pharmacy Address

RITE AID #1050
915 MAIN STREET
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

Rite Aid
Ruth Lightner, Director
(717) 731-6524

Signed By Date

1/9/2013