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GIANT EAGLE PHARMACY #1421
RRC360180-00 CLEVELAND CLINIC HOSPITAL
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Covered Entity Details
Entity Name
CLEVELAND CLINIC HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360180-00
Entity Address
9500 EUCLID AVENUE
CLEVELAND, OH 44195
Medicare Provider Number
360180
Participating Start Date
4/1/2020
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
GIANT EAGLE PHARMACY #1421
Pharmacy Address
2390 PROSPECT AVENUE
ASHTABULA, OH 44004
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Longville, Chief Accounting Officer and Controller
(216) 636-7416
Contract Pharmacy Representative
Giant Eagle, Inc.
Mike Bianco, Senior Pharmacy Manager
(412) 967-3718
Signed By Date
7/14/2020
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