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MEIJER PHARMACY #142
RRC360065-00 FISHER-TITUS MEDICAL CENTER
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Covered Entity Details
Entity Name
FISHER-TITUS MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360065-00
Entity Address
272 BENEDICT AVE
NORWALK, OH 44857
Medicare Provider Number
360065
Participating Start Date
1/1/2017
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
MEIJER PHARMACY #142
Pharmacy Address
4702 MILAN ROAD
SANDUSKY, OH 44870
Pharmacy Comments
Contract Details
Approval Date
10/12/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent W Burkey, MD, President
(440) 660-2550
Contract Pharmacy Representative
Meijer
Katy Diaz, Pharmacy Business Associate
(616) 791-3127
Signed By Date
10/12/2021
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