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DSH510038F STONEWALL JACKSON MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
STONEWALL JACKSON MEMORIAL HOSPITAL
Subdivision Name
Weston ENT and Audiology/ENT Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH510038F
Medicare Provider Number
510038
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/1/2018
Participating Start Date
1/1/2019
Participating Approval Date
10/3/2018
Last Recertification Date
8/19/2019
Termination Date
Termination Reason
10/1/2020
Site closure
Contacts
Authorizing Official
Stonewall Jackson Memorial Hospital
Kevin Stalnaker, Chief Administrative Officer
(304) 269-8152
Primary Contact
Stonewall Jackson Memorial Hospital
John Edward Pope, Director of Pharmacy
(304) 269-8092
Addresses
Street Address
456 Suite B Marketplace Mall
Weston, WV 26452
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date (1/1/2013) until terminated effective date (10/01/2018), reinstatement effective date (01/01/2019)
10/02/2018
April 2025
April 2025
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