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RITE AID OF OHIO, INC.
CAH511304-00 Marietta Memorial Hospital of Tyler County, Inc. DBA Sistersville General Hospital
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Covered Entity Details
Entity Name
Marietta Memorial Hospital of Tyler County, Inc. DBA Sistersville General Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511304-00
Entity Address
314 South Wells St
Sistersville, WV 26175
Medicare Provider Number
511304
Participating Start Date
1/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
RITE AID OF OHIO, INC.
Pharmacy Address
RITE AID #2795
148 NORTH MAIN STREET
WOODSFIELD, OH 43793
Pharmacy Comments
Contract Details
Approval Date
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/18/2023
Agreement registered in error
Contacts
Covered Entity Signing Official
Doug Full, Director of Finance
(740) 374-1698
Contract Pharmacy Representative
Rite Aid
Charlene Kaiser, VP, Managed Care Operations
(918) 645-6652
Signed By Date
7/17/2023
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