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MADISON FAMILY PHARMACY, LLC
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
MADISON FAMILY PHARMACY, LLC
Pharmacy Address
313 MADISON AVENUE
MADISON, WV 25130-1510
Pharmacy Comments
Contract Details
Approval Date
4/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/13/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
RANDELL Davis FOXX, CFO
(304) 369-1230 Ext: 5508
Contract Pharmacy Representative
Charles Burdette, Owner
(304) 369-0209
Signed By Date
4/11/2017
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