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BLACK DIAMOND PHARMACY
DSH510086 WELCH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
WELCH COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510086
Entity Address
454 MCDOWELL STREET
WELCH, WV 24801
Medicare Provider Number
510086
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
BLACK DIAMOND PHARMACY
Pharmacy Address
33800 COAL HERITAGE ROAD
PO BOX 397
NORTHFORK, WV 24868
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Johnny R Brant, CFO
(304) 436-8461
Contract Pharmacy Representative
Black Diamond Pharmacy
David Dunson, Owner
(304) 862-2105
Signed By Date
1/14/2020
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