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OHIO CVS STORES, L.L.C.
DSH360077 FAIRVIEW HOSPITAL
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Covered Entity Details
Entity Name
FAIRVIEW HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360077
Entity Address
18101 LORAIN AVE
CLEVELAND, OH 44111
Medicare Provider Number
360077
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04300
13777 PEARL RD.
STRONGSVILLE, OH 44136
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/11/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Neil P. Smith, President - Fairview Hospital
(216) 476-4499
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/14/2021
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