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PHILLIPS PHARMACY
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
PHILLIPS PHARMACY
Pharmacy Address
329 2ND ST
SAINT MARYS, WV 26170-1005
Pharmacy Comments
Contract Details
Approval Date
1/13/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2021
Ownership change
Contacts
Covered Entity Signing Official
Brandon Chadock, CEO
(304) 447-2420
Contract Pharmacy Representative
Phillips Pharmacy
Tammy Smith, Owner
(304) 684-3784
Signed By Date
1/13/2021
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