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WAL-MART PHARMACY 10-0742
RRC440017-00 HOLSTON VALLEY HOSP & MED CTR
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Covered Entity Details
Entity Name
HOLSTON VALLEY HOSP & MED CTR
Subdivision Name
HOLSTON VALLEY HOSP & MED CTR
Type
Rural Referral Center
340B ID
RRC440017-00
Entity Address
130 W. RAVINE
KINGSPORT, TN 37662-0238
Medicare Provider Number
440017
Participating Start Date
7/1/2022
Last Recertification Date
9/4/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0742
Pharmacy Address
2500 WEST STONE DRIVE
KINGSPORT, TN 37660
Pharmacy Comments
Contract Details
Approval Date
12/12/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alice Pope, EVP and CFO
(423) 230-8209
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
12/12/2014
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