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WEST VIRGINIA CVS PHARMACY, L.L.C.
DSH510038 STONEWALL JACKSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
STONEWALL JACKSON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510038
Entity Address
230 Hospital Plaza
WESTON, WV 26452
Medicare Provider Number
510038
Participating Start Date
1/1/2019
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WEST VIRGINIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05947
250 COURT STREET
WESTON, WV 26452
Pharmacy Comments
Contract Details
Approval Date
7/9/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dodie Arbogast, Controller
(304) 269-8050
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
7/9/2013
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