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FRUTH PHCY
DSH360054 HOLZER
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Covered Entity Details
Entity Name
HOLZER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360054
Entity Address
100 JACKSON PIKE
GALLIPOLIS, OH 45631
Medicare Provider Number
360054
Participating Start Date
7/1/2006
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
FRUTH PHCY
Pharmacy Address
FRUTH PHARMACY #21
204 SECOND AVENUE
GALLIPOLIS, OH 45631
Pharmacy Comments
Contract Details
Approval Date
7/30/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher Meyer, Chief Medical Officer
(740) 446-5051
Contract Pharmacy Representative
Fruth Pharmacy
Tom Willoughby, Chief Financial Officer
(304) 675-1612 Ext: 163
Signed By Date
7/30/2015
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