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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
WALGREENS #18423
1490 E MAIN ST.
HARRISVILLE, WV 26362-7700
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Doug Full, Director of Finance
(740) 374-1698
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/11/2021
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