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KPH HEALTHCARE SERVICES, INC.
SCH330157-00 SAMARITAN MEDICAL CENTER
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Covered Entity Details
Entity Name
SAMARITAN MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH330157-00
Entity Address
830 WASHINGTON STREET
WATERTOWN, NY 13601
Medicare Provider Number
330157
Participating Start Date
10/1/2017
Last Recertification Date
9/16/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #42
21 NYS ROUTE 12
ALEXANDRIA BAY, NY 13607
Pharmacy Comments
Contract Details
Approval Date
8/8/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas H. Carman, President & CEO
(315) 785-4121
Contract Pharmacy Representative
Debbi Barber, Director of PBM Relations
(315) 287-3600 Ext: 2423
Signed By Date
8/8/2017
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