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TENNESSEE CVS PHARMACY, L.L.C.
RRC440017-02 HOLSTON VALLEY HOSP & MED CTR
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Covered Entity Details
Entity Name
HOLSTON VALLEY HOSP & MED CTR
Subdivision Name
Comprehensive Breast Center / Radiology Breast Center
Type
Rural Referral Center
340B ID
RRC440017-02
Entity Address
103 W. Stone Drive
Kingpsport, TN 37660
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
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