340B Drug Pricing Program Database
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DSH360218E LICKING MEMORIAL HOSPITAL (Active)
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Main Details
Name
LICKING MEMORIAL HOSPITAL
Subdivision Name
Licking Memorial Hospital Pain Management - Pain Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH360218E
Medicare Provider Number
360218
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/6/2025
Participating Start Date
4/1/2025
Participating Approval Date
2/3/2025
Last Recertification Date
Contacts
Authorizing Official
Licking Memorial Hospital
Cynthia L. Webster, Chief Financial Officer
(220) 564-4518
Primary Contact
Licking Memorial hospital
Robert Merrill Fish, Jr., Pharmacy Business Manager
(220) 564-4598
Addresses
Street Address
2000 Tamarack Road
Newark, OH 43055
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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