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SPROUT'S DRUG STORE INC
CAH391313-00 CHARLES COLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CHARLES COLE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH391313-00
Entity Address
1001 EAST 2ND STREET
COUDERSPORT, PA 16915
Medicare Provider Number
391313
Participating Start Date
8/25/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
SPROUT'S DRUG STORE INC
Pharmacy Address
122 EAST ACADEMY STREET
BOX 339
SHINGLEHOUSE, PA 16748-0339
Pharmacy Comments
Contract Details
Approval Date
2/7/2012
Contract Begin Date
3/1/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/10/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
EDWARD C PITCHFORD, PRESIDENT & CEO
(814) 260-5216
Contract Pharmacy Representative
Joseph R. Sprout, President & Treasurer
(814) 697-6331
Signed By Date
2/1/2012
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