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THE PHARMACY AT BERGHEIM
CAH451373-00 Ward Memorial Hospital
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Covered Entity Details
Entity Name
Ward Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451373-00
Entity Address
406 S Gary St
Monahans, TX 79756-0040
Medicare Provider Number
451373
Participating Start Date
7/1/2014
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
THE PHARMACY AT BERGHEIM
Pharmacy Address
PREMIUM PHARMA
814 MYER LANE
KERMIT, TX 79745
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leticia C. Rodriguez, CEO
(432) 943-2511 Ext: 176
Contract Pharmacy Representative
PREMIER PHARMACY
ROLANDO RAMON, MANAGER
(210) 298-9000
Signed By Date
10/11/2019
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