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MEIJER STORES LIMITED PARTNERSHIP
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
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
10/3/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew Shawn Doyle, President & CEO
(219) 886-4608
Contract Pharmacy Representative
Meijer
Jeff Romano, Hospital Programs
(616) 791-3171
Signed By Date
10/3/2016
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