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PROPRIUM PHARMACY
DSH490013 HALIFAX REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
HALIFAX REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490013
Entity Address
2204 Wilborn Avenue
SOUTH BOSTON, VA 24592
Medicare Provider Number
490013
Participating Start Date
3/15/2022
Last Recertification Date
9/8/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
PROPRIUM PHARMACY
Pharmacy Address
535 INDEPENDENCE PKWY STE 400
CHESAPEAKE, VA 23320-5176
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Brian Keith Zwoyer, President
(434) 517-3196
Contract Pharmacy Representative
Sentara Enterprises
Jim R Schwamburger, Director
(757) 553-3211
Signed By Date
1/14/2021
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