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FRUTH PHARMACY #16
DSH360008 SOUTHERN OHIO MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHERN OHIO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360008
Entity Address
1805 27TH STREET
PORTSMOUTH, OH 45662
Medicare Provider Number
360008
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FRUTH PHARMACY #16
Pharmacy Address
101 JAMES RD
WAVERLY, OH 45690-1017
Pharmacy Comments
Contract Details
Approval Date
6/13/2012
Contract Begin Date
6/13/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DEAN WRAY, CFO
(740) 356-8540
Contract Pharmacy Representative
Fruth Pharmacy
Tom Willoughby, Chief Financial Officer
(304) 675-1612 Ext: 163
Signed By Date
5/31/2012
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