340B Drug Pricing Program Database
Home
Search
Search Covered Entities
Search Contract Pharmacies
Search Manufacturers
Reports
Help
Login
MEDICAL PARK 11 PHARMACY
DSH150101 WHITLEY MEMORIAL HOSPITAL
Print
Covered Entity Details
Entity Name
WHITLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150101
Entity Address
1260 E STATE ROAD 205
COLUMBIA CITY, IN 46725-9492
Medicare Provider Number
150101
Participating Start Date
10/1/2015
Last Recertification Date
8/15/2018
Entity Termination Date
7/1/2019
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
5/30/2019
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
Continue Your Session
For security reasons inactive sessions are automatically closed.
Your session will be closed shortly if you don't continue it.
Continue Your Session