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WALGREEN CO.
CAH511316-00 GRANT MEMORIAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
GRANT MEMORIAL HOSPITAL, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511316-00
Entity Address
117 HOSPITAL DRIVE
PETERSBURG, WV 26847
Medicare Provider Number
511316
Participating Start Date
8/12/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS #19801
50 S MAIN ST
PETERSBURG, WV 26847-1728
Pharmacy Comments
Contract Details
Approval Date
2/20/2018
Contract Begin Date
2/21/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mary Beth Barr, Chief Executive Officer
(304) 257-1026 Ext: 5800
Contract Pharmacy Representative
Grant Memorial Hospital
Brent R Harman, Director of Pharmacy
(304) 257-1026 Ext: 2440
Signed By Date
2/20/2018
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