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NIKKI'S HOMETOWN PHARMACY LLC
DSH040017 NORTH ARKANSAS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH ARKANSAS REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040017
Entity Address
620 NORTH MAIN STREET
HARRISON, AR 72601
Medicare Provider Number
040017
Participating Start Date
10/1/2010
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
NIKKI'S HOMETOWN PHARMACY LLC
Pharmacy Address
324 W. BOWER AVE.
HARRISON, AR 72601
Pharmacy Comments
Contract Details
Approval Date
10/11/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Vincent Leist, CEO
(870) 414-5155
Contract Pharmacy Representative
Micheal Sullins, Owner/General Manager
(870) 741-7455
Signed By Date
10/11/2016
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