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PROCARE PHARMACY, L.L.C.
DSH150104 WITHAM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WITHAM MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150104
Entity Address
2605 N. LEBANON STREET
LEBANON, IN 46052
Medicare Provider Number
150104
Participating Start Date
5/19/2020
Last Recertification Date
9/12/2022
Entity Termination Date
7/1/2023
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
4/15/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
George Pogas, SR VP of Finance/CFO
(765) 485-8102
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2023
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