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GIANT EAGLE PHARMACY #4016
CAH361323-00 Aultman Orrville Hospital
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Covered Entity Details
Entity Name
Aultman Orrville Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361323-00
Entity Address
832 SOUTH MAIN STREET
ORRVILLE, OH 44667
Medicare Provider Number
361323
Participating Start Date
1/1/2011
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
GIANT EAGLE PHARMACY #4016
Pharmacy Address
11031 STATE RT 212, NE
BOLIVAR, OH 44612
Pharmacy Comments
Contract Details
Approval Date
10/6/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jonathan Dale Basso, Associate CFO
(330) 684-4763
Contract Pharmacy Representative
GIANT EAGLE
Mike Bianco, President & CEO
(412) 967-3718
Signed By Date
10/6/2020
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