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THE LANE DRUG COMPANY
CAH361301-00 Community Memorial Hospital
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Covered Entity Details
Entity Name
Community Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361301-00
Entity Address
208 Columbus Street
Hicksville, OH 43526
Medicare Provider Number
361301
Participating Start Date
1/1/2014
Last Recertification Date
8/31/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
THE LANE DRUG COMPANY
Pharmacy Address
RITE AID #2372
1000 NORTH WILLIAMS STREET
PAULDING, OH 45879
Pharmacy Comments
Contract Details
Approval Date
1/12/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Roy E Davis, CEO
(419) 542-5566
Contract Pharmacy Representative
Rite Aid
Charlene Kaiser, VP, Managed Care Operations
(918) 645-6652
Signed By Date
1/12/2023
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