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WALNUT GROVE PLAZA PHARMACY #2
DSH440131 BAPTIST MEMORIAL HOSPITAL- TIPTON
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Covered Entity Details
Entity Name
BAPTIST MEMORIAL HOSPITAL- TIPTON
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440131
Entity Address
1995 HIGHWAY 51 S
COVINGTON, TN 38019-2338
Medicare Provider Number
440131
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
11/26/2023
Ownership change
Contacts
Covered Entity Signing Official
Monique Hart, Chief Finanacial Officer
(901) 475-5526
Contract Pharmacy Representative
Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144
Signed By Date
2/9/2017
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