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SAM ALEXANDER PHARMACY
DSH040017B NORTH ARKANSAS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH ARKANSAS REGIONAL MEDICAL CENTER
Subdivision Name
MARSHALL FAMILY PRACTICE CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH040017B
Entity Address
211 AIRPORT ROAD
MARSHALL, AR 72650
Medicare Provider Number
040017
Outpatient Facility Provider Number
Participating Start Date
10/1/2010
Last Recertification Date
8/15/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
SAM ALEXANDER PHARMACY
Pharmacy Address
M&T VENTURES LLC
127 N MAIN ST
HARRISON, AR 72601
Pharmacy Comments
Contract Details
Approval Date
7/14/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Richard McBryde, COO
(870) 414-5156
Contract Pharmacy Representative
Sam Alexander Pharmacy
Matt Willmott, Owner
(870) 741-6511
Signed By Date
7/14/2014
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