Contract Pharmacy Details

WALNUT GROVE PLAZA PHARMACY #2
DSH250006 BAPTIST MEMORIAL HOSPITAL - UNION COUNTY

Covered Entity Details

Entity Name

BAPTIST MEMORIAL HOSPITAL - UNION COUNTY

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH250006

Entity Address

200 STATE HIGHWAY 30 W
NEW ALBANY, MS 38652-3112

Medicare Provider Number

250006

Participating Start Date

9/4/2008

Last Recertification Date

8/26/2024

Pharmacy Details

Pharmacy Name

WALNUT GROVE PLAZA PHARMACY #2

Pharmacy Address

6027 WALNUT GROVE RD
STE 110
MEMPHIS, TN 38120-2115

Pharmacy Comments

Contract Details

Approval Date

2/9/2017

Contract Begin Date

4/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/12/2023
Ownership change

Contacts

Covered Entity Signing Official

WALTER GRACE, CEO AND ADMINISTRATOR
(662) 538-2100

Contract Pharmacy Representative

Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144

Signed By Date

2/9/2017

340B Drug Pricing Program Database