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MEIJER PHARMACY #103
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
MEIJER PHARMACY #103
Pharmacy Address
5858 SPRINGBORO PIKE
DAYTON, OH 45449
Pharmacy Comments
Contract Details
Approval Date
7/23/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/24/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SCOTT SHELTON, CFO
(937) 208-4026
Contract Pharmacy Representative
Meijer
Jeff Romano, Hospital Programs
(616) 791-3171
Signed By Date
7/23/2014
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