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WALGREEN CO.
DSH490114B LONESOME PINE HOSPITAL
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Covered Entity Details
Entity Name
LONESOME PINE HOSPITAL
Subdivision Name
Ballad Health Cancer Care - A Department of Lonesome Pine Hospital
Type
Disproportionate Share Hospital
340B ID
DSH490114B
Entity Address
743 Island Road
Bristol, VA 24201
Medicare Provider Number
490114
Outpatient Facility Provider Number
Participating Start Date
1/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05597
2200 MEMORIAL BLVD.
KINGSPORT, TN 37664
Pharmacy Comments
Contract Details
Approval Date
1/12/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alice Pope, EVP and CFO
(423) 230-8209
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/12/2015
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