Contract Pharmacy Details

NC BAPTIST HOSPITAL, INC
DSH340096 LEXINGTON MEMORIAL HOSPITAL, INC.

Covered Entity Details

Entity Name

LEXINGTON MEMORIAL HOSPITAL, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH340096

Entity Address

250 HOSPITAL DRIVE
LEXINGTON, NC 27292

Medicare Provider Number

340096

Participating Start Date

9/9/2005

Last Recertification Date

9/16/2019

Entity Termination Date

1/1/2020

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

340B Drug Pricing Program Database