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OHIO CVS STORES, L.L.C.
CAH361329-00 WYANDOT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WYANDOT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361329-00
Entity Address
885 N Sandusky Ave
UPPER SANDUSKY, OH 43351
Medicare Provider Number
361329
Participating Start Date
8/19/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03432
535 DELAWARE AVE
MARION, OH 43302
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/16/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TY SHAULL, COO
(419) 294-4991 Ext: 2263
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/15/2020
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