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WAL-MART PHARMACY 10-3749
DSH360134 THE GOOD SAMARITAN HOSPITAL OF CINCINNATI OHIO
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Covered Entity Details
Entity Name
THE GOOD SAMARITAN HOSPITAL OF CINCINNATI OHIO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360134
Entity Address
375 DIXMYTH AVE
CINCINNATI, OH 45220
Medicare Provider Number
360134
Participating Start Date
4/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3749
Pharmacy Address
2801 CUNNINGHAM DRIVE
CINCINNATI, OH 45241
Pharmacy Comments
Contract Details
Approval Date
4/13/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Crofton, Sr. Vice President & CFO
(513) 569-6577
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/13/2015
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