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AULTMAN HOSPITAL
CAH361323-00 Aultman Orrville Hospital
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Covered Entity Details
Entity Name
Aultman Orrville Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361323-00
Entity Address
832 SOUTH MAIN STREET
ORRVILLE, OH 44667
Medicare Provider Number
361323
Participating Start Date
1/1/2011
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
AULTMAN HOSPITAL
Pharmacy Address
D.B.A AULTMAN HEALTH PHARMACY SERVICES
2500 WALES AVE NW STE B
MASSILLON, OH 44646
Pharmacy Comments
Contract Details
Approval Date
4/5/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/23/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Tyler Lee Immel, Executive Director of Finance
(330) 363-4790
Contract Pharmacy Representative
Aultman Employee Pharmacy
Tom Casey, Assistant Manager Retail Pharmacy
(330) 363-5489
Signed By Date
4/5/2023
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