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CVPH OUTPATIENT PHARMACY INC.
DSH330250 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
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Covered Entity Details
Entity Name
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330250
Entity Address
75 BEEKMAN STREET
PLATTSBURGH, NY 12901
Medicare Provider Number
330250
Participating Start Date
6/3/2019
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
CVPH OUTPATIENT PHARMACY INC.
Pharmacy Address
DBA THE PRESCRIPTION SHOPPE
214 CORNELIA STREET
SUITE 101-01
PLATTSBURGH, NY 12901
Pharmacy Comments
Contract Details
Approval Date
9/24/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOYCE RAFFERTY, VICE PRESIDENT OF FINANCE
(518) 562-7047
Contract Pharmacy Representative
Condo Pharmacy Inc.
Steve Moore, Manager
(518) 563-3400
Signed By Date
9/24/2014
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