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CLEVELAND CLINIC LUTHERAN AMBULATORY PHA
DSH360087 LUTHERAN HOSPITAL
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Covered Entity Details
Entity Name
LUTHERAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360087
Entity Address
1730 WEST 25TH STREET
CLEVELAND, OH 44113
Medicare Provider Number
360087
Participating Start Date
4/1/2006
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CLEVELAND CLINIC LUTHERAN AMBULATORY PHA
Pharmacy Address
1730 W 25TH ST
CLEVELAND, OH 44113
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matt Mattner, Vice President of Operations
(216) 363-2275
Contract Pharmacy Representative
Cleveland Clinic
Donald Carroll, Associate Chief Pharmacy Officer
(216) 374-3584
Signed By Date
10/12/2018
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