Contract Pharmacy Details

LEECHBURG HEALTHMART PHARMACY
DSH390090 West Penn Hospital

Covered Entity Details

Entity Name

West Penn Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH390090

Entity Address

4800 FRIENDSHIP AVE
PITTSBURGH, PA 15224-1722

Medicare Provider Number

390090

Participating Start Date

10/20/2005

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

LEECHBURG HEALTHMART PHARMACY

Pharmacy Address

165 MARKET ST
LEECHBURG, PA 15656-1334

Pharmacy Comments

Contract Details

Approval Date

9/20/2012

Contract Begin Date

9/20/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/31/2024
Pharmacy closed

Contacts

Covered Entity Signing Official

Duke Rupert, CEO and President
(412) 578-1176

Contract Pharmacy Representative

Alex Micklow, Secretary
(724) 842-1771

Signed By Date

8/31/2012