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WAL-MART PHARMACY 10-3829
DSH440032 HAWKINS COUNTY MEMORIAL HOSPITAL
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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
WAL-MART PHARMACY 10-3829
Pharmacy Address
2915 WEST MARKET STREET
JOHNSON CITY, TN 37604
Pharmacy Comments
Contract Details
Approval Date
4/9/2015
Contract Begin Date
7/1/2015
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
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/9/2015
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