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FILLMORE & FISHER PHCY
DSH330103 OLEAN GENERAL HOSPITAL
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Covered Entity Details
Entity Name
OLEAN GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330103
Entity Address
515 MAIN STREET
OLEAN, NY 14760
Medicare Provider Number
330103
Participating Start Date
10/1/2019
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
FILLMORE & FISHER PHCY
Pharmacy Address
DBA CUBA PHARMACY
2 CENTER ST
CUBA, NY 14727
Pharmacy Comments
Contract Details
Approval Date
8/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Richard G. Braun Jr., SVP Finance and CFO
(716) 375-6190
Contract Pharmacy Representative
Fillmore and Fisher Pharmacy
Rick Wonderling, Owner
(585) 567-2228
Signed By Date
7/11/2019
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