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WILSON PHARMACY
DSH490002 RUSSELL COUNTY HOSPITAL
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Covered Entity Details
Entity Name
RUSSELL COUNTY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490002
Entity Address
58 Carroll Street
LEBANON, VA 24266
Medicare Provider Number
490002
Participating Start Date
4/22/2020
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WILSON PHARMACY
Pharmacy Address
DBA BALLAD HEALTH PHARMACY
523 N STATE OF FRANKLIN RD
JOHNSON CITY, TN 37604
Pharmacy Comments
11/16/2012 address update (was 525 N. State of Franklin Rd.)
Contract Details
Approval Date
10/10/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
John Lawrence Jeter, CFO
(276) 258-2800
Contract Pharmacy Representative
MSHA
Trish Tanner, AVP Pharmacy Services
(423) 302-3532
Signed By Date
10/10/2013
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