Contract Pharmacy Details

WALGREEN CO.
SCH510082-00 SUMMERSVILLE REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

SUMMERSVILLE REGIONAL MEDICAL CENTER

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH510082-00

Entity Address

400 FAIRVIEW HEIGHTS ROAD
SUMMERSVILLE, WV 26651

Medicare Provider Number

510082

Participating Start Date

7/1/2017

Last Recertification Date

8/15/2018

Entity Termination Date

4/1/2019

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #11981
5870 WEBSTER RD.
SUMMERSVILLE, WV 26651

Pharmacy Comments

Contract Details

Approval Date

7/17/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/10/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

John Timothy Lewis, CNO, COO
(304) 872-2891

Contract Pharmacy Representative

Summersville Regional Medical Center
Robert Schaub, Director of Pharmacy
(304) 872-8437

Signed By Date

7/17/2018

340B Drug Pricing Program Database