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RIVERSIDE MED BLDG PHARMACY
DSH360017 GRANT MEDICAL CENTER
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Covered Entity Details
Entity Name
GRANT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360017
Entity Address
111 S Grant Avenue
COLUMBUS, OH 43215
Medicare Provider Number
360017
Participating Start Date
9/9/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
RIVERSIDE MED BLDG PHARMACY
Pharmacy Address
3545 OLENTANGY RIVER RD STE 100
COLUMBUS, OH 43214-3998
Pharmacy Comments
Contract Details
Approval Date
1/11/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/18/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gaston Bushiri, VP Finance
(614) 955-2002
Contract Pharmacy Representative
OhioHealth
Paul Higginbotham, Director - Pharmacy Services
(614) 533-5262
Signed By Date
1/11/2021
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