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COMMUNITY PHARMACY
DSH150072 MEMORIAL HOSPITAL LOGANSPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL LOGANSPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150072
Entity Address
1101 MICHIGAN AVENUE
LOGANSPORT, IN 46947
Medicare Provider Number
150072
Participating Start Date
4/1/2023
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
COMMUNITY PHARMACY
Pharmacy Address
COMMUNITY PHARMACY
1201 MICHIGAN AVE STE 100
LOGANSPORT, IN 46947
Pharmacy Comments
Contract Details
Approval Date
9/2/2009
Contract Begin Date
9/2/2009
Carve-In Effective Date
Contract Comments
11/30/09 UPDATED ADDR TO REMOVE SUITE# (WAS SUITE 100)
Contract Termination Date
Termination Reason
7/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
ALAN BIGGS, COO
(574) 753-1317
Contract Pharmacy Representative
BRIAN SHOCKNEY, PRESIDENT
(574) 753-1385
Signed By Date
8/19/2009
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