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MEIJER PHARMACY #125
DSH150021 Parkview Hospital
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Covered Entity Details
Entity Name
Parkview Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150021
Entity Address
11109 PARKVIEW PLAZA DRIVE
FORT WAYNE, IN 46845
Medicare Provider Number
150021
Participating Start Date
10/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
MEIJER PHARMACY #125
Pharmacy Address
5909 ILLINOIS ROAD
FORT WAYNE, IN 46804
Pharmacy Comments
Contract Details
Approval Date
7/16/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/13/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeanne Wickens, CFO
(260) 373-8407
Contract Pharmacy Representative
Meijer
Rick Keyes, President/CEO
(616) 453-6711
Signed By Date
7/16/2019
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