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CITY HOSPITAL INC
CAH511319-00 JEFFERSON MEDICAL CENTER
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Covered Entity Details
Entity Name
JEFFERSON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511319-00
Entity Address
300 S. PRESTON STREET
RANSON, WV 25438-1631
Medicare Provider Number
511319
Participating Start Date
9/29/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
CITY HOSPITAL INC
Pharmacy Address
DBA BERKELEY MEDICAL CENTER
2500 HOSPITAL DR
MARTINSBURG, WV 25401-3402
Pharmacy Comments
Contract Details
Approval Date
1/2/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHRISTINA DEROSA, CHIEF ADMINISTRATIVE OFFICER
(304) 724-1075
Contract Pharmacy Representative
Berkeley Medical Center
Christian Miller, Director of Pharmacy
(304) 264-1219
Signed By Date
1/2/2014
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