Contract Pharmacy Details

HOOK-SUPERX, L.L.C.
DSH150169 COMMUNITY HOSPITAL OF INDIANA INC.

Covered Entity Details

Entity Name

COMMUNITY HOSPITAL OF INDIANA INC.

Subdivision Name

Community Hospital North

Type

Disproportionate Share Hospital

340B ID

DSH150169

Entity Address

7150 CLEARVISTA DRIVE
INDIANAPOLIS, IN 46256

Medicare Provider Number

150169

Participating Start Date

4/1/2016

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

HOOK-SUPERX, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06610
8405 SOUTHEASTERN AVE.
INDIANAPOLIS, IN 46239

Pharmacy Comments

Contract Details

Approval Date

7/10/2019

Contract Begin Date

10/1/2019

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Dee Moonesinghe, Physician Executive
(765) 437-2959

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/10/2019

340B Drug Pricing Program Database