Contract Pharmacy Details

OHIO CVS STORES, L.L.C.
SCH360040-00 KNOX COMMUNITY HOSPITAL

Covered Entity Details

Entity Name

KNOX COMMUNITY HOSPITAL

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH360040-00

Entity Address

1330 COSHOCTON AVE
MOUNT VERNON, OH 43050

Medicare Provider Number

360040

Participating Start Date

10/1/2014

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

OHIO CVS STORES, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03992
620 S. CLEVELAND AVE.
WESTERVILLE, OH 43081

Pharmacy Comments

Contract Details

Approval Date

4/13/2020

Contract Begin Date

5/19/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2021
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

MICHAEL AMBROSIANI, CHIEF FINANCIAL OFFICER
(740) 393-9623

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

4/13/2020

340B Drug Pricing Program Database