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FRED'S PHARMACY #1661
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
FRED'S PHARMACY #1661
Pharmacy Address
1131 N CHARLYNE AVE
BRINKLEY, AR 72021-2105
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/9/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Stephen Mette, Chief Clinical Officer
(501) 686-8111
Contract Pharmacy Representative
Tim Liebmann, EVP & COO Pharmacy
(901) 238-2634
Signed By Date
1/17/2017
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