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CENTERVILLE LONG TERM CARE
CH0511330 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Samaritan Homeless Clinic
Type
HRSA-Funded Health Center
340B ID
CH0511330
Entity Address
921 S Edwin C Moses Blvd
Dayton, OH 45417-3464
Grant Number
H80CS00027
Participating Start Date
7/1/2005
Last Recertification Date
2/10/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
CENTERVILLE LONG TERM CARE
Pharmacy Address
PHARMACY
9352B LEBANON PIKE
CENTERVILLE, OH 45458
Pharmacy Comments
Contract Details
Approval Date
1/21/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/18/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane M. Cummins, CEO
(937) 461-1376 Ext: 228
Contract Pharmacy Representative
Caren Mowbray, Owner
(937) 435-5751
Signed By Date
1/21/2014
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