Contract Pharmacy Details

SOUTH FORK PHARMACY
CAH511316-00 GRANT MEMORIAL HOSPITAL, INC.

Covered Entity Details

Entity Name

GRANT MEMORIAL HOSPITAL, INC.

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH511316-00

Entity Address

117 HOSPITAL DRIVE
PETERSBURG, WV 26847

Medicare Provider Number

511316

Participating Start Date

8/12/2010

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

SOUTH FORK PHARMACY

Pharmacy Address

WILLIAMS PHARMACY HOLDINGS #1, LLC
732 N MAIN ST
MOOREFIELD, WV 26836

Pharmacy Comments

Contract Details

Approval Date

7/8/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/2/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

JOE BARNES, CHIEF FINANCIAL OFFICER
(304) 257-1026 Ext: 5802

Contract Pharmacy Representative

South Fork Pharmacy
Bradley Williams, Owner
(304) 530-1044

Signed By Date

7/8/2014

340B Drug Pricing Program Database