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MEDICAL PARK 11 PHARMACY
CAH151310-00 Parkview Wabash Hospital, Inc
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Covered Entity Details
Entity Name
Parkview Wabash Hospital, Inc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151310-00
Entity Address
10 John Kissinger Drive
WABASH, IN 46992-1914
Medicare Provider Number
151310
Participating Start Date
8/12/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MEDICAL PARK 11 PHARMACY
Pharmacy Address
11104 PARKVIEW CIRCLE DR
FORT WAYNE, IN 46845-1704
Pharmacy Comments
Contract Details
Approval Date
7/3/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/22/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeanne Wickens, CFO
(260) 373-8407
Contract Pharmacy Representative
Medical Park 11
Shery Grosjean, Pharmacy Manager
(260) 266-4507
Signed By Date
7/3/2018
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