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PUNXSY HOMETOWN PHARMACY, LLC
DSH390086 DUBOIS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
DUBOIS REGIONAL MEDICAL CENTER
Subdivision Name
dba Penn Highlands DuBois
Type
Disproportionate Share Hospital
340B ID
DSH390086
Entity Address
100 HOSPITAL AVENUE
DUBOIS, PA 15801
Medicare Provider Number
390086
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
PUNXSY HOMETOWN PHARMACY, LLC
Pharmacy Address
PUNXSY HOMETOWN PHARMACY
GROUNDHOG PLAZA
203 NORTH HAMPTON AVENUE
PUNXSUTAWNEY, PA 15767-1576
Pharmacy Comments
Contract Details
Approval Date
4/9/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Brian Kline, CFO
(814) 375-6377
Contract Pharmacy Representative
Nickolas Kernich, Pharmacy Manager
(814) 938-9150
Signed By Date
4/9/2013
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