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GIANT EAGLE PHARMACY #0216
DSH360037 ST. VINCENT CHARITY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. VINCENT CHARITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360037
Entity Address
2351 EAST 22ND STREET
CLEVELAND, OH 44115
Medicare Provider Number
360037
Participating Start Date
1/1/2001
Last Recertification Date
9/12/2022
Entity Termination Date
1/1/2023
Pharmacy Details
Pharmacy Name
GIANT EAGLE PHARMACY #0216
Pharmacy Address
30320 LAKE SHORE BLVD
WILLOWICK, OH 44095
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/12/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOHN Rusnaczyk, CFO
(216) 363-7718 Ext: 37718
Contract Pharmacy Representative
GIANT EAGLE
Mike Bianco, President & CEO
(412) 967-3718
Signed By Date
10/15/2019
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