Contract Pharmacy Details

FRED'S PHARMACY
DSH440151 Saint Thomas River Park Hospital, LLC d/b/a Ascension Saint Thomas River Park

Covered Entity Details

Entity Name

Saint Thomas River Park Hospital, LLC d/b/a Ascension Saint Thomas River Park

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH440151

Entity Address

1559 SPARTA ROAD
MCMINNVILLE, TN 37110

Medicare Provider Number

440151

Participating Start Date

4/1/2017

Last Recertification Date

9/5/2024

Pharmacy Details

Pharmacy Name

FRED'S PHARMACY

Pharmacy Address

912 N. CHANCERY STREET
MCMINNVILLE, TN 37110

Pharmacy Comments

Contract Details

Approval Date

7/18/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/1/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Lisa R. Davis, TN Ministry Market CFO Saint Thomas
(615) 284-6845

Contract Pharmacy Representative

Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153

Signed By Date

7/18/2017

340B Drug Pricing Program Database