Contract Pharmacy Details

TENNESSEE CVS PHARMACY, L.L.C.
DSH440032 HAWKINS COUNTY MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

HAWKINS COUNTY MEMORIAL HOSPITAL

Subdivision Name

WELLMONT HEALTH SYSTEM

Type

Disproportionate Share Hospital

340B ID

DSH440032

Entity Address

851 LOCUST STREET
ROGERSVILLE, TN 37857

Medicare Provider Number

440032

Participating Start Date

7/1/2018

Last Recertification Date

9/10/2018

Entity Termination Date

1/1/2019

Pharmacy Details

Pharmacy Name

TENNESSEE CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03792
420 PARK BLVD., #5
ROGERSVILLE, TN 37857

Pharmacy Comments

Contract Details

Approval Date

10/13/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/1/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Alice Pope, EVP and CFO
(423) 230-8209

Contract Pharmacy Representative

CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241

Signed By Date

10/13/2014

340B Drug Pricing Program Database