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RITE AID OF WEST VIRGINIA, INC.
CAH511313-00 BOONE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
BOONE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511313-00
Entity Address
701 Madison Avenue
MADISON, WV 25130
Medicare Provider Number
511313
Participating Start Date
1/1/2011
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
RITE AID OF WEST VIRGINIA, INC.
Pharmacy Address
RITE AID #2460
901 MAIN STREET
P.O. BOX 4547
CHAPMANVILLE, WV 25508
Pharmacy Comments
Contract Details
Approval Date
10/19/2012
Contract Begin Date
10/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/16/2018
Ownership change
Contacts
Covered Entity Signing Official
RANDELL Davis FOXX, CFO
(304) 369-1230 Ext: 5508
Contract Pharmacy Representative
Rite Aid
Ruth Lightner, Director
(717) 731-6524
Signed By Date
9/21/2012
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