Contract Pharmacy Details

BRIOVARX
DSH360025 FIRELANDS REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

FIRELANDS REGIONAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH360025

Entity Address

1111 HAYES AVENUE
SANDUSKY, OH 44870

Medicare Provider Number

360025

Participating Start Date

1/1/2017

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

BRIOVARX

Pharmacy Address

BRIOVARX, LLC
206 ROXALANA BUSINESS PARK
DUNBAR, WV 25064-2727

Pharmacy Comments

Contract Details

Approval Date

7/9/2019

Contract Begin Date

10/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/1/2019
Pharmacy closed

Contacts

Covered Entity Signing Official

Daniel J. Moncher, Executive Vice President & CFO
(419) 557-7793

Contract Pharmacy Representative

Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677

Signed By Date

7/9/2019

340B Drug Pricing Program Database