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NC BAPTIST HOSPITAL, INC
DSH340096K LEXINGTON MEMORIAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
LEXINGTON MEMORIAL HOSPITAL, INC.
Subdivision Name
Internal Medicine- Lexington
Type
Disproportionate Share Hospital
340B ID
DSH340096K
Entity Address
105 Hospital 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
1/1/2019
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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