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HICKMAN RX DRUGGIST
DSH510046 PRINCETON COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
PRINCETON COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510046
Entity Address
122 12TH STREET
PRINCETON, WV 24740
Medicare Provider Number
510046
Participating Start Date
1/1/2009
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
HICKMAN RX DRUGGIST
Pharmacy Address
199 12TH STREET EXT
PRINCETON, WV 24740-2352
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Diane Lynn Spencer, VP of Finance/CFO
(304) 487-7505
Contract Pharmacy Representative
Hickman Pharmacy
John Hickman, Vice President
(304) 425-2188
Signed By Date
4/15/2025
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