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CRESCENT HEALTHCARE, INC.
DSH210019 TIDALHEALTH PENINSULA REGIONAL INC
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Covered Entity Details
Entity Name
TIDALHEALTH PENINSULA REGIONAL INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210019
Entity Address
100 EAST CARROLL STREET
SALISBURY, MD 21801
Medicare Provider Number
210019
Participating Start Date
3/15/2022
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
CRESCENT HEALTHCARE, INC.
Pharmacy Address
1352 W. 15TH ST.
SUITE 8
PANAMA CITY, FL 32401-7411
Pharmacy Comments
Contract Details
Approval Date
7/2/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/12/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Bruce Ritchie, CFO
(410) 543-7298
Contract Pharmacy Representative
Option Care
Jenny Money, Senior Manager, Health Systems Programs
(773) 202-6786
Signed By Date
7/2/2018
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