Contract Pharmacy Details

LEECHBURG HEALTHMART PHARMACY
DSH390090G West Penn Hospital

Covered Entity Details

Entity Name

West Penn Hospital

Subdivision Name

WEST PENN HOSPITAL OUTPATIENT SERVICES AT BUTLER

Type

Disproportionate Share Hospital

340B ID

DSH390090G

Entity Address

160 Hollywood Dr
BUTLER, PA 16001-5600

Medicare Provider Number

390090

Outpatient Facility Provider Number

Participating Start Date

7/1/2010

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