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PROCARE PHARMACY, L.L.C.
DSH150072 MEMORIAL HOSPITAL LOGANSPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL LOGANSPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150072
Entity Address
1101 MICHIGAN AVENUE
LOGANSPORT, IN 46947
Medicare Provider Number
150072
Participating Start Date
4/1/2023
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
4/10/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
SHERRI GEHLHAUSEN, CFO
(574) 753-1502
Contract Pharmacy Representative
cvs
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
4/10/2023
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