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OHIO CVS STORES, L.L.C.
DSH360077 FAIRVIEW HOSPITAL
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Covered Entity Details
Entity Name
FAIRVIEW HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360077
Entity Address
18101 LORAIN AVE
CLEVELAND, OH 44111
Medicare Provider Number
360077
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03332
14000 RIDGE ROAD
NORTH ROYALTON, OH 44133
Pharmacy Comments
Contract Details
Approval Date
4/12/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Clifford Mills, Executive Director-Hospital Operations, West Submarket
(216) 492-4803
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/12/2022
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