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WAL-MART PHARMACY #10-2474
CAH511315-00 POTOMAC VALLEY HOSPITAL
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Covered Entity Details
Entity Name
POTOMAC VALLEY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511315-00
Entity Address
100 PIN OAK LANE
KEYSER, WV 26726
Medicare Provider Number
511315
Participating Start Date
4/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY #10-2474
Pharmacy Address
R.R. #4 BOX 82
KEYSER, WV 26726
Pharmacy Comments
Contract Details
Approval Date
10/12/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Justin Gibson, VP of Finance-North Region
(304) 598-4256
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/12/2021
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