Contract Pharmacy Details

INNOVATIVE MEDS RX
DSH340003 NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY

Covered Entity Details

Entity Name

NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH340003

Entity Address

830 ROCKFORD STREET
MOUNT AIRY, NC 27030

Medicare Provider Number

340003

Participating Start Date

7/1/2004

Last Recertification Date

9/5/2018

Entity Termination Date

4/1/2019

Pharmacy Details

Pharmacy Name

INNOVATIVE MEDS RX

Pharmacy Address

DBA GATES PHARMACY
364 N SOUTH ST
MOUNT AIRY, NC 27030

Pharmacy Comments

Contract Details

Approval Date

7/14/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Robin Hodgin, VP Patient Care Services
(336) 719-7019

Contract Pharmacy Representative

Neil L. Edlen, Vice President
(336) 789-5050

Signed By Date

7/14/2014

340B Drug Pricing Program Database