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MILLER PHARMACEUTICAL CARE, LLC
CAH361301-00 Community Memorial Hospital
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Covered Entity Details
Entity Name
Community Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361301-00
Entity Address
208 Columbus Street
Hicksville, OH 43526
Medicare Provider Number
361301
Participating Start Date
1/1/2014
Last Recertification Date
8/31/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
MILLER PHARMACEUTICAL CARE, LLC
Pharmacy Address
DBA ANTWERP PHARMACY
201 S. MAIN ST.
ANTWERP, OH 45813
Pharmacy Comments
Contract Details
Approval Date
10/23/2020
Contract Begin Date
10/23/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Benjamin Fiser, CIO
(419) 542-5678
Contract Pharmacy Representative
Antwerp Pharmacy
Amanda Miller, Owner
(419) 258-2068
Signed By Date
10/23/2020
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