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FIVE RIVERS HEALTH CENTERS
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
FIVE RIVERS HEALTH CENTERS
Pharmacy Address
721 MIAMI CHAPEL RD
DAYTON, OH 45417
Pharmacy Comments
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
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 Cummins, Chief Operating Officer
(937) 734-6838
Contract Pharmacy Representative
Nicole Crase, Pharmacist
(937) 208-8850
Signed By Date
4/15/2014
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