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KMART PHARMACY
DSH510030 Davis Memorial Hospital DBA DAVIS MEDICAL CENTER
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Covered Entity Details
Entity Name
Davis Memorial Hospital DBA DAVIS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510030
Entity Address
812 Gorman Avenue
ELKINS, WV 26241
Medicare Provider Number
510030
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KMART PHARMACY
Pharmacy Address
731 BEVERLY PIKE
ELKINS, WV 26241
Pharmacy Comments
Contract Details
Approval Date
4/14/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
REBECCA J. HAMMER, VICE PRESIDENT FOR FINANCE
(304) 637-3156
Contract Pharmacy Representative
Jeff Newell, VP Pharmacy Administration &Compliance
(847) 286-5084
Signed By Date
4/14/2016
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