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DISCOUNT DRUG MART #73
DSH360051 MIAMI VALLEY HOSPITAL
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Covered Entity Details
Entity Name
MIAMI VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360051
Entity Address
ONE WYOMING STREET
DAYTON, OH 45409
Medicare Provider Number
360051
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
DISCOUNT DRUG MART #73
Pharmacy Address
7617 DAYTON-SPRINGFIELD RD
FAIRBORN, OH 45324
Pharmacy Comments
Contract Details
Approval Date
1/20/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/22/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SCOTT SHELTON, CFO
(937) 208-4026
Contract Pharmacy Representative
Discount Drug Mart
Pete Ratycz, Vice President of Pharmacy
(330) 725-2340
Signed By Date
1/20/2014
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