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KMART CORPORATION
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
KMART CORPORATION
Pharmacy Address
57 CENTRE DRIVE
PLATTSBURGH, NY 12901
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2017
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
Sears
Jennifer Speares, Director of Administration and Compliance
(847) 286-5116
Signed By Date
4/15/2016
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