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PROCARE PHARMACY, L.L.C.
DSH360008 SOUTHERN OHIO MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHERN OHIO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360008
Entity Address
1805 27TH STREET
PORTSMOUTH, OH 45662
Medicare Provider Number
360008
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DEAN WRAY, CFO
(740) 356-8540
Contract Pharmacy Representative
SOMC
DEAN WRAY, CFO
(740) 356-8540
Signed By Date
4/15/2021
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