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OHIO CVS STORES, L.L.C.
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
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06184
555 E. STATE ST.
ATHENS, OH 45701
Pharmacy Comments
Contract Details
Approval Date
10/10/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jerel T. Humphrey, EVP - Acute Care Services
(740) 446-5021
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/10/2016
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