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CYSTIC FIBROSIS SERVICES, LLC
SCH510082-00 SUMMERSVILLE REGIONAL MEDICAL CENTER
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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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
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
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