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WAL-MART PHARMACY 10-2684
CAH511304-00 Marietta Memorial Hospital of Tyler County, Inc. DBA Sistersville General Hospital
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Covered Entity Details
Entity Name
Marietta Memorial Hospital of Tyler County, Inc. DBA Sistersville General Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511304-00
Entity Address
314 South Wells St
Sistersville, WV 26175
Medicare Provider Number
511304
Participating Start Date
1/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2684
Pharmacy Address
1142 SO. BRIDGE STREET
NEW MARTINSVILLE, WV 26155
Pharmacy Comments
Contract Details
Approval Date
4/16/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John May, CEO
(304) 447-2509
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/16/2014
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