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STULTZ PHARMACY OF WHEELERSBURG, INC
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
STULTZ PHARMACY OF WHEELERSBURG, INC
Pharmacy Address
8991 OHIO RIVER RD
WHEELERSBURG, OH 45694
Pharmacy Comments
Contract Details
Approval Date
7/2/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DEAN WRAY, CFO
(740) 356-8540
Contract Pharmacy Representative
Brad Stultz, CEO
(606) 922-5512
Signed By Date
7/2/2013
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