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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
7/7/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Randal White, CEO
(765) 827-7987
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/7/2017
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