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OHIO CVS STORES, L.L.C.
DSH360008 SOUTHERN OHIO MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHERN OHIO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360008
Entity Address
1805 27TH STREET
PORTSMOUTH, OH 45662
Medicare Provider Number
360008
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05429
521 EAST STATE STREET
GEORGETOWN, OH 45121
Pharmacy Comments
Contract Details
Approval Date
1/4/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DEAN WRAY, CFO
(740) 356-8540
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/4/2020
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