Contract Pharmacy Details

ERLANGER PHARMACIES
DSH440104C Erlanger Health

Covered Entity Details

Entity Name

Erlanger Health

Subdivision Name

PACC Ambulatory Surgery

Type

Disproportionate Share Hospital

340B ID

DSH440104C

Entity Address

975 East Third Street
Chattanooga, TN 37403

Medicare Provider Number

440104

Outpatient Facility Provider Number

Participating Start Date

4/1/2013

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

ERLANGER PHARMACIES

Pharmacy Address

DBA ERLANGER PHARMACY
1200 DODSON AVENUE
CHATTANOOGA, TN 37406

Pharmacy Comments

Contract Details

Approval Date

4/15/2013

Contract Begin Date

7/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2017
Pharmacy closed

Contacts

Covered Entity Signing Official

BRITTON J. TABOR, CFO
(423) 778-7729

Contract Pharmacy Representative

Donna Bourdon, President
(423) 386-1017

Signed By Date

4/15/2013