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NC BAPTIST HOSPITAL, INC
DSH340096F LEXINGTON MEMORIAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
LEXINGTON MEMORIAL HOSPITAL, INC.
Subdivision Name
Cardiology
Type
Disproportionate Share Hospital
340B ID
DSH340096F
Entity Address
14 Medical Park Drive
Lexington, NC 27292
Medicare Provider Number
340096
Outpatient Facility Provider Number
Participating Start Date
7/1/2016
Last Recertification Date
8/16/2018
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
NC BAPTIST HOSPITAL, INC
Pharmacy Address
MEDICAL CENTER BLVD
ATTN NC BAPTIST HOSP PHAR
WINSTON SALEM, NC 27157
Pharmacy Comments
Contract Details
Approval Date
4/18/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/16/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
DANNY SQUIRES, CFO
(336) 248-5161
Contract Pharmacy Representative
NORTH CAROLINA BAPTIST HOSPITAL
Martin Konopko, System Manager 340b
(336) 713-9418
Signed By Date
4/18/2018
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