Contract Pharmacy Details

DE MOTTE DRUGS
DSH150002 THE METHODIST HOSPITALS

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

5001 E DUNES HWY
GARY, IN 46403

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