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AFFILIATED HEALTH SERVICES, INC.
DSH150100 ST. MARYS MEDICAL CENTER D/B/A ASCENSION ST VINCENT EVANSVILLE
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Covered Entity Details
Entity Name
ST. MARYS MEDICAL CENTER D/B/A ASCENSION ST VINCENT EVANSVILLE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150100
Entity Address
3700 WASHINGTON AVE
EVANSVILLE, IN 47750
Medicare Provider Number
150100
Participating Start Date
7/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
AFFILIATED HEALTH SERVICES, INC.
Pharmacy Address
DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/27/2022
Ownership change
Contacts
Covered Entity Signing Official
Daniel Allen Parod, President
(317) 338-7094
Contract Pharmacy Representative
Ascension Michigan Pharmacy
Deborah Sopo, Pharmacy Manager
(248) 865-3770
Signed By Date
4/14/2020
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