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WALGREEN CO.
CAH511304-00 Marietta Memorial Hospital of Tyler County, Inc. DBA Sistersville General Hospital
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Covered Entity Details
Entity Name
Marietta Memorial Hospital of Tyler County, Inc. DBA Sistersville General Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511304-00
Entity Address
314 South Wells St
Sistersville, WV 26175
Medicare Provider Number
511304
Participating Start Date
1/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11238
615 RANDOLPH AVE.
ELKINS, WV 26241-3950
Pharmacy Comments
Contract Details
Approval Date
7/2/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brandon Chadock, CEO
(304) 447-2420
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/2/2020
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