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SHAKAMAK HEALTH INC
CAH151327-00 Sullivan County Community Hospital
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Covered Entity Details
Entity Name
Sullivan County Community Hospital
Subdivision Name
SULLIVAN COUNTY COMMUNITY HOSPITAL
Type
Critical Access Hospital
340B ID
CAH151327-00
Entity Address
2200 NORTH SECTION STREET
SULLIVAN, IN 47882
Medicare Provider Number
151327
Participating Start Date
9/29/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
SHAKAMAK HEALTH INC
Pharmacy Address
D/B/A SHAKAMAK PHARMACY
346 E MAIN ST
JASONVILLE, IN 47438
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/23/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MICHELLE FRANKLIN, CHIEF EXECUTIVE OFFICER
(812) 268-4311 Ext: 2372
Contract Pharmacy Representative
shakamak pharmacy
traver lee wolf, owner
(812) 665-9760
Signed By Date
1/15/2021
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