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NICHOLAS PHARMACY, INC
DSH510082 SUMMERSVILLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SUMMERSVILLE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510082
Entity Address
400 FAIRVIEW HEIGHTS ROAD
SUMMERSVILLE, WV 26651
Medicare Provider Number
510082
Participating Start Date
4/1/2017
Last Recertification Date
8/25/2015
Entity Termination Date
7/1/2017
Pharmacy Details
Pharmacy Name
NICHOLAS PHARMACY, INC
Pharmacy Address
421 MAIN STREET
SUMMERSVILLE, WV 26651
Pharmacy Comments
Contract Details
Approval Date
7/21/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
Brian Kelbaugh, CFO
(304) 872-8571
Contract Pharmacy Representative
Jerry H. Leonard, Director of Pharmacy
(304) 345-4836 Ext: 220
Signed By Date
7/21/2014
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