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NORTHSIDE PAVILION PHARMACY
DSH360039 GENESIS HEALTHCARE SYSTEM
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Covered Entity Details
Entity Name
GENESIS HEALTHCARE SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360039
Entity Address
2951 MAPLE AVE.
ZANESVILLE, OH 43701-1406
Medicare Provider Number
360039
Participating Start Date
7/1/2007
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
NORTHSIDE PAVILION PHARMACY
Pharmacy Address
945 BETHESDA DR
ZANESVILLE, OH 43701-0801
Pharmacy Comments
Contract Details
Approval Date
4/1/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/19/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
PAUL D. MASTERSON, CFO
(740) 454-4637
Contract Pharmacy Representative
Rod Stickrath, Director
(740) 454-5666 Ext: 7014
Signed By Date
4/1/2014
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