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ST ANNE MERCY OUTPATIENT PHAR
DSH360112 MERCY HEALTH - ST. VINCENT MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY HEALTH - ST. VINCENT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360112
Entity Address
2213 CHERRY STREET
TOLEDO, OH 43608
Medicare Provider Number
360112
Participating Start Date
1/1/2005
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
ST ANNE MERCY OUTPATIENT PHAR
Pharmacy Address
3404 W SYLVANIA AVE
TOLEDO, OH 43623-4467
Pharmacy Comments
08/13/2014 - Pharmacy name and address correction, changed in error on 3/28/2013, see history for details
Contract Details
Approval Date
11/7/2012
Contract Begin Date
11/7/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/3/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robert Moon, Senior VP and Regional CFO - Mercy
(419) 251-0755
Contract Pharmacy Representative
BRADLEY BERTKE, President-CEO
(419) 407-2400
Signed By Date
9/6/2012
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