Contract Pharmacy Details

OHIO CVS STORES, L.L.C.
DSH510012 PLEASANT VALLEY HOSPITAL

Covered Entity Details

Entity Name

PLEASANT VALLEY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH510012

Entity Address

2520 VALLEY DRIVE
POINT PLEASANT, WV 25550

Medicare Provider Number

510012

Participating Start Date

7/1/2006

Last Recertification Date

8/14/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

OHIO CVS STORES, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 04400
3066 STATE RT. 160
GALLIPOLIS, OH 45631

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

4/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Craig Gilliland, Chief Financial Officer
(304) 675-4340 Ext: 1398

Contract Pharmacy Representative

CVS
MARK KELLY, Director of Business Development
(619) 402-0671

Signed By Date

1/14/2020

340B Drug Pricing Program Database