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TRINITY INFUSION
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
TRINITY INFUSION
Pharmacy Address
327 6TH AVE
SOUTH CHARLESTON, WV 25303-1231
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Brian L Ulery, Chief Operating Officer (COO)
(304) 766-3445
Contract Pharmacy Representative
Eppy's IV DBA Trinity Infusion
Chad A Wallace, Pharmacy Director
(304) 746-7201
Signed By Date
1/12/2018
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