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WEST VIRGINIA CVS PHARMACY, L.L.C.
DSH510053 ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
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Covered Entity Details
Entity Name
ST. JOSEPH'S HOSPITAL OF BUCKHANNON, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510053
Entity Address
ONE AMALIA DRIVE
BUCKHANNON, WV 26201
Medicare Provider Number
510053
Participating Start Date
1/1/2005
Last Recertification Date
8/19/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
WEST VIRGINIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 07649
74 WEST MAIN ST.
BUCKHANNON, WV 26201
Pharmacy Comments
Contract Details
Approval Date
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
Renee A. Hofer, Controller
(304) 473-2185
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/15/2014
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