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FILLMORE PHARMACY
CAH361329-00 WYANDOT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WYANDOT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361329-00
Entity Address
885 N Sandusky Ave
UPPER SANDUSKY, OH 43351
Medicare Provider Number
361329
Participating Start Date
8/19/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
FILLMORE PHARMACY
Pharmacy Address
119 S SYCAMORE AVE
SYCAMORE, OH 44882
Pharmacy Comments
Contract Details
Approval Date
10/12/2021
Contract Begin Date
10/12/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
TY SHAULL, COO
(419) 294-4991 Ext: 2263
Contract Pharmacy Representative
Fillmore Pharmacy
Kevin Pelter, Owner
(419) 927-2691
Signed By Date
10/12/2021
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