Contract Pharmacy Details

TENNESSEE CVS PHARMACY, L.L.C.
RRC440017-03 HOLSTON VALLEY HOSP & MED CTR

Covered Entity Details

Entity Name

HOLSTON VALLEY HOSP & MED CTR

Subdivision Name

Holston Valley Med Center Diagnostic Center / Cardiovascular Stress Testing

Type

Rural Referral Center

340B ID

RRC440017-03

Entity Address

2050 Meadowview Parkway
Kingsport, 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 # 04240
4400 W. STONE DRIVE
KINGSPORT, TN 37660

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