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FRED'S PHARMACY #1661
DSH040072 BAPTIST HEALTH MEDICAL CENTER - STUTTGART
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Covered Entity Details
Entity Name
BAPTIST HEALTH MEDICAL CENTER - STUTTGART
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040072
Entity Address
1703 NORTH BUERKLE
STUTTGART, AR 72160
Medicare Provider Number
040072
Participating Start Date
1/1/2011
Last Recertification Date
9/18/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
FRED'S PHARMACY #1661
Pharmacy Address
1131 N CHARLYNE AVE
BRINKLEY, AR 72021-2105
Pharmacy Comments
Contract Details
Approval Date
10/4/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/16/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Fred's Pharmacy
Betty Ngo, Sr. Director 340B Program Operations
(901) 481-0346
Signed By Date
10/4/2016
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