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GOLUB CORPORATION
DSH330250 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
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Covered Entity Details
Entity Name
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330250
Entity Address
75 BEEKMAN STREET
PLATTSBURGH, NY 12901
Medicare Provider Number
330250
Participating Start Date
6/3/2019
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
GOLUB CORPORATION
Pharmacy Address
MARKET 32 PHARMACY 168
19 CENTRE DRIVE
PLATTSBURGH, NY 12901
Pharmacy Comments
Contract Details
Approval Date
10/11/2022
Contract Begin Date
11/28/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/10/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Christopher Hickey, Sr. Vice President/Chief Financial Officer
(518) 481-8067
Contract Pharmacy Representative
Golub Corporation
Scott Guisinger, Vice President of Pharmacy
(518) 379-2409
Signed By Date
10/11/2022
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