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KENTUCKY CVS PHARMACY, L.L.C.
RRC150082-00 DEACONESS HOSPITAL
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Covered Entity Details
Entity Name
DEACONESS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC150082-00
Entity Address
600 MARY STREET
EVANSVILLE, IN 47747
Medicare Provider Number
150082
Participating Start Date
10/20/2021
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
KENTUCKY CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06377
920 N. MAIN ST.
MADISONVILLE, KY 42431
Pharmacy Comments
Contract Details
Approval Date
10/20/2021
Contract Begin Date
10/20/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/21/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cheryl Wathen, Chief Financial Officer
(812) 450-3296
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/12/2021
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