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HOOK-SUPERX, L.L.C.
CAH151331-04 HARRISON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
HARRISON COUNTY HOSPITAL
Subdivision Name
First Capial Medical Group - Primary Care
Type
Critical Access Hospital
340B ID
CAH151331-04
Entity Address
1263 Hospital Dr NW
250
Corydon, IN 47112
Medicare Provider Number
151331
Outpatient Facility Provider Number
Participating Start Date
10/1/2022
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
HOOK-SUPERX, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03280
255 OLD CAPITAL PLAZA NW
CORYDON, IN 47112
Pharmacy Comments
Contract Details
Approval Date
10/12/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa Marie Lieber, Chief Administrative Officer
(812) 738-7884
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/12/2023
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