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MEDICAL PARK 11 PHARMACY
DSH150091 HUNTINGTON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
HUNTINGTON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150091
Entity Address
2001 STULTS ROAD
HUNTINGTON, IN 46750
Medicare Provider Number
150091
Participating Start Date
7/1/2022
Last Recertification Date
8/14/2024
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
7/6/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
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
7/6/2018
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