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BEACON HC PHARMACY SB
DSH150058 MEMORIAL HOSPITAL OF SOUTH BEND, INC
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF SOUTH BEND, INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150058
Entity Address
615 N MICHIGAN STREET
SOUTH BEND, IN 46601
Medicare Provider Number
150058
Participating Start Date
1/1/2007
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
BEACON HC PHARMACY SB
Pharmacy Address
3355 DOUGLAS RD.
SOUTH BEND, IN 46635
Pharmacy Comments
Contract Details
Approval Date
11/29/2011
Contract Begin Date
12/1/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kreg Gruber, Chief Operating Officer
(574) 647-6795
Contract Pharmacy Representative
Beacon Health System-Elkhart General Hospital
Holly Kaczmarek, Director of Pharmacy
(574) 523-3447
Signed By Date
12/1/2011
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