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NORTHSIDE NEW CONCORD PHARMACY
DSH360039E GENESIS HEALTHCARE SYSTEM
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Covered Entity Details
Entity Name
GENESIS HEALTHCARE SYSTEM
Subdivision Name
GENESIS HEALTHCARE FIRST CARE NORTH
Type
Disproportionate Share Hospital
340B ID
DSH360039E
Entity Address
2800 MAPLE AVE.
ZANESVILLE, OH 43701
Medicare Provider Number
360039
Outpatient Facility Provider Number
Participating Start Date
4/1/2008
Last Recertification Date
8/17/2016
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
NORTHSIDE NEW CONCORD PHARMACY
Pharmacy Address
10 E MAIN ST
NEW CONCORD, OH 43762-1286
Pharmacy Comments
Contract Details
Approval Date
12/2/2010
Contract Begin Date
1/1/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
11/23/2010
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