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KPH HEALTHCARE SERVICES, INC.
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
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #10
300 MAIN STREET
MASSENA, NY 13662
Pharmacy Comments
Contract Details
Approval Date
1/18/2023
Contract Begin Date
2/8/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2024
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
KPH Healthcare Services, Inc.
Debbi Barber, 340B Program Director
(315) 287-3600 Ext: 2423
Signed By Date
1/18/2023
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