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FAMILY LIFE PHARMACY
CAH511313-00 BOONE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
BOONE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511313-00
Entity Address
701 Madison Avenue
MADISON, WV 25130
Medicare Provider Number
511313
Participating Start Date
1/1/2011
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
FAMILY LIFE PHARMACY
Pharmacy Address
FAMILY LIFE PHARMACY
21189 COAL RIVER RD
COMFORT, WV 25049
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/19/2023
Ownership change
Contacts
Covered Entity Signing Official
Virgil Lee Underwood, CEO
(304) 369-1230 Ext: 5507
Contract Pharmacy Representative
Family Life Pharmacy
Stephanie Massey, Co-Owner
(304) 837-3777
Signed By Date
7/14/2021
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