Contract Pharmacy Details

VAN PHARMACY, INC
FQHCLA128 HYGEIA FACILITIES FOUNDATION, INC.

Covered Entity Details

Entity Name

HYGEIA FACILITIES FOUNDATION, INC.

Subdivision Name

RALEIGH BOONE MEDICAL CENTER

Type

Health Center Program Look-Alike

340B ID

FQHCLA128

Entity Address

37456 COAL RIVER ROAD
WHITESVILLE, WV 25209

Grant Number

LALCS00039

Participating Start Date

4/1/2004

Last Recertification Date

2/27/2023

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

VAN PHARMACY, INC

Pharmacy Address

19024 POND FORK ROAD
PO BOX 450
VAN, WV 25206

Pharmacy Comments

Contract Details

Approval Date

4/9/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Margaret L. Martin, Executive Director
(304) 854-1323

Contract Pharmacy Representative

Van Pharmacy, Inc.
Robin Moore, Pharmacy Manager
(304) 245-8255

Signed By Date

4/9/2018

340B Drug Pricing Program Database