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HOOK-SUPERX, L.L.C.
DSH150064 FAYETTE MEMORIAL HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
FAYETTE MEMORIAL HOSPITAL ASSOCIATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150064
Entity Address
1941 VIRGINIA AVENUE
CONNERSVILLE, IN 47331
Medicare Provider Number
150064
Participating Start Date
4/1/2010
Last Recertification Date
9/4/2018
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
HOOK-SUPERX, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06652
301 N. GRAND AVE
CONNERSVILLE, IN 47331
Pharmacy Comments
Contract Details
Approval Date
10/8/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Debra Michalek, CFO
(765) 827-7989
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/8/2014
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