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WAL-MART PHARMACY 10-4483
DSH440065 NorthCrest Medical Center
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Covered Entity Details
Entity Name
NorthCrest Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440065
Entity Address
100 NorthCrest Drive
Springfield, TN 37172
Medicare Provider Number
440065
Participating Start Date
10/1/2012
Last Recertification Date
8/6/2015
Entity Termination Date
7/1/2016
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4483
Pharmacy Address
222 WILKINSON LANE
WHITE HOUSE, TN 37188
Pharmacy Comments
Contract Details
Approval Date
1/7/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
James F. Schmidt, CFO
(615) 384-1503
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/7/2014
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