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KEESEVILLE 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
KEESEVILLE PHARMACY INC
Pharmacy Address
KEESEVILLE PHARMACY
1730 FRONT ST
KEESEVILLE, NY 12944-3618
Pharmacy Comments
Contract Details
Approval Date
4/13/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JOYCE RAFFERTY, VICE PRESIDENT OF FINANCE
(518) 562-7047
Contract Pharmacy Representative
CORNERSTONE DRUG AND GIFT
Dan Bosley, RPh
(518) 297-3784
Signed By Date
4/13/2017
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