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LEECHBURG HEALTHMART PHARMACY
DSH390090F West Penn Hospital
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Covered Entity Details
Entity Name
West Penn Hospital
Subdivision Name
WEST PENN HOSPITAL OUTPATIENT SERVICES AT MELLON PAVILION
Type
Disproportionate Share Hospital
340B ID
DSH390090F
Entity Address
4815 LIBERTY AVENUE
SUITE 340
PITTSBURGH, PA 15224-2156
Medicare Provider Number
390090
Outpatient Facility Provider Number
Participating Start Date
1/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
LEECHBURG HEALTHMART PHARMACY
Pharmacy Address
165 MARKET ST
LEECHBURG, PA 15656-1334
Pharmacy Comments
Contract Details
Approval Date
9/20/2012
Contract Begin Date
9/20/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Duke Rupert, CEO and President
(412) 578-1176
Contract Pharmacy Representative
Alex Micklow, Secretary
(724) 842-1771
Signed By Date
8/31/2012
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