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GIANT EAGLE PHARMACY #6376
DSH360077 FAIRVIEW HOSPITAL
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Covered Entity Details
Entity Name
FAIRVIEW HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360077
Entity Address
18101 LORAIN AVE
CLEVELAND, OH 44111
Medicare Provider Number
360077
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
GIANT EAGLE PHARMACY #6376
Pharmacy Address
6300 BIDDULPH ROAD
BROOKLYN, OH 44144
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
1/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Neil P. Smith, President - Fairview Hospital
(216) 476-4499
Contract Pharmacy Representative
Giant Eagle, Inc.
Mike Bianco, Senior Pharmacy Manager
(412) 967-3718
Signed By Date
7/14/2020
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