Contract Pharmacy Details

COMPREHENSIVE CANCER CENTER PHARMACY
DSH340096P LEXINGTON MEMORIAL HOSPITAL, INC.

Covered Entity Details

Entity Name

LEXINGTON MEMORIAL HOSPITAL, INC.

Subdivision Name

Wound Care Center

Type

Disproportionate Share Hospital

340B ID

DSH340096P

Entity Address

10 Medical Park Drive
3
Lexington, NC 27292

Medicare Provider Number

340096

Outpatient Facility Provider Number

Participating Start Date

4/1/2018

Last Recertification Date

9/2/2019

Entity Termination Date

1/1/2020

Pharmacy Details

Pharmacy Name

COMPREHENSIVE CANCER CENTER PHARMACY

Pharmacy Address

NORTH CAROLINA BAPTIST HOSPITAL
MEDICAL CENTER BLVD
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