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WAL-MART PHARMACY 10-5315
DSH360239 SYCAMORE HOSPITAL
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Covered Entity Details
Entity Name
SYCAMORE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360239
Entity Address
4000 Miamisburg-Centerville Rd
MIAMISBURG, OH 45342
Medicare Provider Number
360239
Participating Start Date
1/1/2017
Last Recertification Date
9/10/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
William E Villegas, Regional VP of Finance
(937) 723-3414
Contract Pharmacy Representative
Kettering Health Network:Grandview/Kettering/Ft Hamilton/Sycamore/Soin
Linda McCall, Pharmacy Director
(937) 458-4946
Signed By Date
7/15/2020
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