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KROGER PHARMACY #16594
CAH361329-00 WYANDOT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WYANDOT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361329-00
Entity Address
885 N Sandusky Ave
UPPER SANDUSKY, OH 43351
Medicare Provider Number
361329
Participating Start Date
8/19/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #16594
Pharmacy Address
790 W MARKET ST
TIFFIN, OH 44883
Pharmacy Comments
Contract Details
Approval Date
7/6/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/2/2023
Agreement registered in error
Contacts
Covered Entity Signing Official
TY SHAULL, COO
(419) 294-4991 Ext: 2263
Contract Pharmacy Representative
340B Direct
Ginger Ison, Vice President of Sales
(801) 716-4863
Signed By Date
7/6/2023
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