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SMITH COUNTRY CLUB DRUG STORE
DSH040016 UNIVERSITY OF ARKANSAS HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY OF ARKANSAS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040016
Entity Address
4301 WEST MARKHAM ST
Slot 571
LITTLE ROCK, AR 72205
Medicare Provider Number
040016
Participating Start Date
12/1/1992
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SMITH COUNTRY CLUB DRUG STORE
Pharmacy Address
5114 KAVANAUGH BLVD
LITTLE ROCK, AR 72207-4607
Pharmacy Comments
Contract Details
Approval Date
4/4/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MELISSA FONTAINE, Chief Operating Officer
(501) 686-8955
Contract Pharmacy Representative
Patricia Ingles, Owner
(501) 663-4118
Signed By Date
4/4/2013
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