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CORNER DRUG STORE
DSH040119 WHITE RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
WHITE RIVER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040119
Entity Address
1710 HARRISON STREET
BATESVILLE, AR 72501
Medicare Provider Number
040119
Participating Start Date
7/1/2009
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
CORNER DRUG STORE
Pharmacy Address
CORNER DRUG STORE
LISAGARDNER99@MAC.COM
830 EAST MAIN STREET
MELBOURNE, AR 72556-7255
Pharmacy Comments
Contract Details
Approval Date
4/14/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/2/2020
Ownership change
Contacts
Covered Entity Signing Official
Jana Richardson, Controller
(870) 262-3222
Contract Pharmacy Representative
Caeverett, Inc.
Lisa Gardner, Owner
(870) 368-7171
Signed By Date
4/14/2015
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