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SOUTH FORK PHARMACY
CAH511316-00 GRANT MEMORIAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
GRANT MEMORIAL HOSPITAL, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511316-00
Entity Address
117 HOSPITAL DRIVE
PETERSBURG, WV 26847
Medicare Provider Number
511316
Participating Start Date
8/12/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SOUTH FORK PHARMACY
Pharmacy Address
WILLIAMS PHARMACY HOLDINGS #1, LLC
732 N MAIN ST
MOOREFIELD, WV 26836
Pharmacy Comments
Contract Details
Approval Date
1/11/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/24/2024
Ownership change
Contacts
Covered Entity Signing Official
Kari L Evans, Corporate Compliance Officer
(304) 257-5816
Contract Pharmacy Representative
South Fork Pharmacy
Bradley Williams, Owner
(304) 530-1044
Signed By Date
1/11/2023
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