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HOLIDAY CVS, 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
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 02030
301 S. 6TH AVE.
WAUCHULA, FL 33873
Pharmacy Comments
Contract Details
Approval Date
4/16/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DEAN WRAY, CFO
(740) 356-8540
Contract Pharmacy Representative
Caremark L.L.C.
Christian reid, 340b Program Director
(401) 770-2118
Signed By Date
4/16/2020
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