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CENTRA CANCER CENTER PHARMACY
DSH490021 CENTRA HEALTH
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Covered Entity Details
Entity Name
CENTRA HEALTH
Subdivision Name
Lynchburg General Hospital
Type
Disproportionate Share Hospital
340B ID
DSH490021
Entity Address
1920 ATHERHOLT ROAD
LYNCHBURG, VA 24501
Medicare Provider Number
490021
Participating Start Date
10/1/2023
Last Recertification Date
8/15/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
CENTRA CANCER CENTER PHARMACY
Pharmacy Address
1701 THOMSON DR
LYNCHBURG, VA 24501-1118
Pharmacy Comments
Contract Details
Approval Date
9/7/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tabitha M. Culbertson, President, Lynchburg General &Virginia Baptist Hospitals
(434) 200-3014
Contract Pharmacy Representative
Centra Health
Randall Puckett, Managing Director of Pharmacy
(434) 200-3179
Signed By Date
7/17/2023
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