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RITE AID OF WEST VIRGINIA, INC.
DSH510012 PLEASANT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
PLEASANT VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510012
Entity Address
2520 VALLEY DRIVE
POINT PLEASANT, WV 25550
Medicare Provider Number
510012
Participating Start Date
7/1/2006
Last Recertification Date
8/14/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
RITE AID OF WEST VIRGINIA, INC.
Pharmacy Address
RITE AID #280
406 WASHINGTON STREET
RAVENSWOOD, WV 26164
Pharmacy Comments
Contract Details
Approval Date
4/9/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/8/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TOM SCHAUER, CHIEF EXECUTIVE OFFICER
(304) 675-4340 Ext: 1387
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/9/2013
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