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CLINIC PHARMACY OF PRINCETON
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
CLINIC PHARMACY OF PRINCETON
Pharmacy Address
508 NEW HOPE ROAD, SUITE 101
PRINCETON, WV 24740
Pharmacy Comments
Contract Details
Approval Date
4/2/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
FRANK SINICROPE, CFO
(304) 487-7263
Contract Pharmacy Representative
Thomas B. Bay, President
(304) 425-9591
Signed By Date
4/2/2014
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