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FRANCISCAN HEALTH MAIN ST. OUTPATIENT CE
DSH150004 FRANCISCAN HEALTH HAMMOND
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Covered Entity Details
Entity Name
FRANCISCAN HEALTH HAMMOND
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150004
Entity Address
5454 HOHMAN AVE
HAMMOND, IN 46320
Medicare Provider Number
150004
Participating Start Date
4/1/2013
Last Recertification Date
8/31/2022
Entity Termination Date
1/1/2023
Pharmacy Details
Pharmacy Name
FRANCISCAN HEALTH MAIN ST. OUTPATIENT CE
Pharmacy Address
1201 S MAIN ST
CROWN POINT, IN 46307
Pharmacy Comments
Contract Details
Approval Date
4/8/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
TOM GRYZBEK, PRESIDENT
(219) 933-2074
Contract Pharmacy Representative
Franciscan Health
Laura Shondell, Administrative Director Medication Systems and Operations
(765) 423-6900
Signed By Date
4/8/2014
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