Contract Pharmacy Details

DISCOUNT DRUG MART INC #14
RRC360065-00 FISHER-TITUS MEDICAL CENTER

Covered Entity Details

Entity Name

FISHER-TITUS MEDICAL CENTER

Subdivision Name

Type

Rural Referral Center

340B ID

RRC360065-00

Entity Address

272 BENEDICT AVE
NORWALK, OH 44857

Medicare Provider Number

360065

Participating Start Date

1/1/2017

Last Recertification Date

9/4/2024

Pharmacy Details

Pharmacy Name

DISCOUNT DRUG MART INC #14

Pharmacy Address

3700 MILAN RD
SANDUSKY, OH 44870

Pharmacy Comments

Contract Details

Approval Date

10/13/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/5/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Brent W Burkey, MD, President
(440) 660-2550

Contract Pharmacy Representative

Discount Drug Mart
Pete Ratycz, Vice President of Pharmacy
(330) 725-2340

Signed By Date

10/13/2020

340B Drug Pricing Program Database