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WALNUT GROVE PLAZA PHARMACY #2
DSH440048 BAPTIST MEM HOSPITAL MEMPHIS
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Covered Entity Details
Entity Name
BAPTIST MEM HOSPITAL MEMPHIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440048
Entity Address
6019 WALNUT GROVE ROAD
MEMPHIS, TN 38120
Medicare Provider Number
440048
Participating Start Date
7/1/2017
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WALNUT GROVE PLAZA PHARMACY #2
Pharmacy Address
6027 WALNUT GROVE RD
STE 110
MEMPHIS, TN 38120-2115
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
12/12/2023
Ownership change
Contacts
Covered Entity Signing Official
David Barham, VP, Operations Finance CFO
(901) 227-7467
Contract Pharmacy Representative
Baptist Memorial Health Care Corp
Donna C Cox, Director 340B
(901) 227-5144
Signed By Date
7/18/2017
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