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WAL-MART PHARMACY 10-1703
DSH510008 City Hospital, Inc. DBA Berkeley Medical Center
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Covered Entity Details
Entity Name
City Hospital, Inc. DBA Berkeley Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510008
Entity Address
2500 HOSPITAL DRIVE
MARTINSBURG, WV 25401
Medicare Provider Number
510008
Participating Start Date
10/1/2007
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1703
Pharmacy Address
800 FOX CROFT AVE
MARTINSBURG, WV 25401
Pharmacy Comments
Contract Details
Approval Date
10/13/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Grover Glendon Kerns, VP of Finance
(304) 260-1443
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/13/2021
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