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PREMIER HEALTH PHARMACY-FIDELITY
DSH360051 MIAMI VALLEY HOSPITAL
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Covered Entity Details
Entity Name
MIAMI VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360051
Entity Address
ONE WYOMING STREET
DAYTON, OH 45409
Medicare Provider Number
360051
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PREMIER HEALTH PHARMACY-FIDELITY
Pharmacy Address
3170 KETTERING BLVD BLDG B
MORAINE, OH 45439
Pharmacy Comments
Contract Details
Approval Date
4/18/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Craig Allen Ganger, Chief Financial Officer
(937) 499-9988
Contract Pharmacy Representative
Premier Health
Eric Napier, Director of Outpatient Pharmacy
(937) 208-6534
Signed By Date
4/18/2021
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