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RIVERSIDE MED BLDG PHARMACY
CAH361324-00 SHELBY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SHELBY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361324-00
Entity Address
199 West Main Street
Shelby, OH 44875
Medicare Provider Number
361324
Participating Start Date
10/1/2017
Last Recertification Date
9/6/2024
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
1/12/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/29/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph S Lyren, VP Finance
(419) 526-8417
Contract Pharmacy Representative
OhioHealth
Paul Higginbotham, Director - Pharmacy Services
(614) 533-5262
Signed By Date
1/12/2021
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