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NORTHSIDE NEW CONCORD PHARMACY
DSH360039B GENESIS HEALTHCARE SYSTEM
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Covered Entity Details
Entity Name
GENESIS HEALTHCARE SYSTEM
Subdivision Name
GOOD SAMARITAN HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH360039B
Entity Address
800 FOREST AVE.
ZANESVILLE, OH 43701-1406
Medicare Provider Number
360039
Outpatient Facility Provider Number
Participating Start Date
7/1/2007
Last Recertification Date
8/28/2015
Entity Termination Date
7/1/2016
Pharmacy Details
Pharmacy Name
NORTHSIDE NEW CONCORD PHARMACY
Pharmacy Address
10 E MAIN ST
NEW CONCORD, OH 43762-1286
Pharmacy Comments
Contract Details
Approval Date
12/2/2010
Contract Begin Date
1/1/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
11/23/2010
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