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MEDICAL PARK 11 PHARMACY
DSH150146 COMMUNITY HOSPITAL OF NOBLE CTY INC
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Covered Entity Details
Entity Name
COMMUNITY HOSPITAL OF NOBLE CTY INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150146
Entity Address
401 N SAWYER ROAD
KENDALLVILLE, IN 46755-0728
Medicare Provider Number
150146
Participating Start Date
7/1/2025
Last Recertification Date
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
4/9/2019
Covered Entity Terminated
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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