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MEDICINE SHOPPE 1088 LLC
CAH361316-02 BUCYRUS COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BUCYRUS COMMUNITY HOSPITAL
Subdivision Name
Provider Based Clinic - Hill Street Suite B (PBC 140B)
Type
Critical Access Hospital
340B ID
CAH361316-02
Entity Address
140 Hill Street
B
Bucyrus, OH 44820
Medicare Provider Number
361316
Outpatient Facility Provider Number
Participating Start Date
1/1/2018
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
MEDICINE SHOPPE 1088 LLC
Pharmacy Address
345 N SANDUSKY AVE
BUCYRUS, OH 44820
Pharmacy Comments
Contract Details
Approval Date
7/13/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eric Draime, CFO
(419) 468-0501
Contract Pharmacy Representative
Medicine Shoppe 1088 LLC
Tamer Ibrahim, President
(330) 412-7442
Signed By Date
7/13/2022
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