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MOUNTAIN LAKE PHARMACY
CAH511322-00 West Virginia Health Care Cooperative, Inc. DBA Summersville Regional Medical Center
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Covered Entity Details
Entity Name
West Virginia Health Care Cooperative, Inc. DBA Summersville Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511322-00
Entity Address
400 FAIRVIEW HEIGHTS ROAD
SUMMERSVILLE, WV 26651
Medicare Provider Number
511322
Participating Start Date
7/1/2019
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
MOUNTAIN LAKE PHARMACY
Pharmacy Address
1129 BROAD ST
STE 100
SUMMERSVILLE, WV 26651
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Timothy Lewis, COO
(304) 872-2891
Contract Pharmacy Representative
Mountain Lake Pharmacy
Howard Stephen Boone, President
(304) 872-9000
Signed By Date
10/14/2019
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