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CLINIC 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
CLINIC DRUG STORE
Pharmacy Address
1700 HARRISON ST STE D
WHITE RIVER MEDICAL ARTS BLDG
BATESVILLE, AR 72501-7315
Pharmacy Comments
Contract Details
Approval Date
7/12/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jana Richardson, Controller
(870) 262-3222
Contract Pharmacy Representative
Philip Baker, Owner and Pharmacist
(870) 793-5170
Signed By Date
7/12/2016
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