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NICKMANS DRUG #119
DSH390184 Highlands Hospital
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Covered Entity Details
Entity Name
Highlands Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390184
Entity Address
401 East Murphy Ave.
Connellsville, PA 15425
Medicare Provider Number
390184
Participating Start Date
7/1/2014
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
NICKMANS DRUG #119
Pharmacy Address
107 MEMORIAL BLVD
CONNELLSVILLE, PA 15425-2653
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John S. Andursky, Chief Executive Officer
(724) 626-2359
Contract Pharmacy Representative
NICKMANS PHARMACY
JOYCE KOSSOL, BUSINESS DEVELOPMENT
(724) 437-5550
Signed By Date
7/15/2021
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