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NW OTTER CREEK, LLC
DSH040114 BAPTIST HEALTH MEDICAL CENTER - LR
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Covered Entity Details
Entity Name
BAPTIST HEALTH MEDICAL CENTER - LR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040114
Entity Address
9601 Baptist Health Drive
LITTLE ROCK, AR 72205
Medicare Provider Number
040114
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
NW OTTER CREEK, LLC
Pharmacy Address
EXPRESS RX OF OTTER CREEK
10100 STAGECOACH RD
LITTLE ROCK, AR 72210
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Express RX
Galen Perkins, CEO
(501) 534-4400
Signed By Date
7/11/2024
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