Contract Pharmacy Details

TENNESSEE CVS PHARMACY, L.L.C.
RRC440017-01 HOLSTON VALLEY HOSP & MED CTR

Covered Entity Details

Entity Name

HOLSTON VALLEY HOSP & MED CTR

Subdivision Name

Holston Valley Med Center Diagnostics / Cardiovascular JC Echo Vascular

Type

Rural Referral Center

340B ID

RRC440017-01

Entity Address

2428 Knob Creek Rd Suite 251
Johnson City, TN 37604

Medicare Provider Number

440017

Outpatient Facility Provider Number

Participating Start Date

7/1/2015

Last Recertification Date

8/18/2021

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

TENNESSEE CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 05664
4106 FT. HENRY DR.
KINGSPORT, TN 37663

Pharmacy Comments

Contract Details

Approval Date

10/13/2017

Contract Begin Date

1/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/1/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Todd j. Dougan, CFO
(423) 230-8512

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/13/2017

340B Drug Pricing Program Database