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OHIO CVS STORES, L.L.C.
SCH360040-00 KNOX COMMUNITY HOSPITAL
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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 # 06148
190 S. SANDUSKY ST.
DELAWARE, OH 43015
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
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