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DE MOTTE DRUGS
DSH150002 THE METHODIST HOSPITALS
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Covered Entity Details
Entity Name
THE METHODIST HOSPITALS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150002
Entity Address
600 GRANT ST
GARY, IN 46402
Medicare Provider Number
150002
Participating Start Date
4/1/2003
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
DE MOTTE DRUGS
Pharmacy Address
FAGEN PHARMACY #33
5500 HOHMAN AVENUE
SUITE 1A
HAMMOND, IN 46320
Pharmacy Comments
Contract Details
Approval Date
4/13/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/2/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
Matthew Shawn Doyle, President & CEO
(219) 886-4608
Contract Pharmacy Representative
Gerald A. Fagen, President
(219) 987-6468
Signed By Date
4/13/2015
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