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WHITLEY MEMORIAL HOSPITAL
DSH150021 Parkview Hospital
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Covered Entity Details
Entity Name
Parkview Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150021
Entity Address
11109 PARKVIEW PLAZA DRIVE
FORT WAYNE, IN 46845
Medicare Provider Number
150021
Participating Start Date
10/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WHITLEY MEMORIAL HOSPITAL
Pharmacy Address
1260 E STATE ROAD 205
COLUMBIA CITY, IN 46725-9492
Pharmacy Comments
Contract Details
Approval Date
4/11/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeanne Wickens, CFO
(260) 373-8407
Contract Pharmacy Representative
Medical Park 11
Shery Grosjean, Pharmacy Manager
(260) 266-4507
Signed By Date
4/11/2024
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