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KPH HEALTHCARE SERVICES, INC.
SCH470024-00 Northwestern Medical Center, Inc.
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Covered Entity Details
Entity Name
Northwestern Medical Center, Inc.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH470024-00
Entity Address
133 Fairfield Street
St. Albans, VT 05478
Medicare Provider Number
470024
Participating Start Date
1/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #18
164 SWANTON ROAD
ST ALBANS, VT 05478
Pharmacy Comments
Contract Details
Approval Date
2/1/2012
Contract Begin Date
2/1/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ted Sirotta, CFO
(802) 524-1042
Contract Pharmacy Representative
Owen Halloran, Senior Vice President, Pharmacy Procurement
(315) 287-3600 Ext: 263
Signed By Date
1/24/2012
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