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K MART PHARMACY #3198
DSH510029 Thomas Memorial Hospital
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Covered Entity Details
Entity Name
Thomas Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510029
Entity Address
4605 MacCorkle Avenue, SW
South Charleston, WV 25309
Medicare Provider Number
510029
Participating Start Date
7/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
K MART PHARMACY #3198
Pharmacy Address
1477 MCCORKLE AVE
ST ALBANS, WV 25177
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Brian L Ulery, Chief Operating Officer (COO)
(304) 766-3445
Contract Pharmacy Representative
Kmart
Jennifer Speares, Director Administration/Compliance
(904) 783-5183
Signed By Date
10/17/2016
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