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WAL-MART PHARMACY 10-2933
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
WAL-MART PHARMACY 10-2933
Pharmacy Address
201 GREASY RIDGE RD
PRINCETON, WV 24739
Pharmacy Comments
Contract Details
Approval Date
1/21/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/21/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
FRANK SINICROPE, CFO
(304) 487-7263
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/21/2014
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