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PARKVIEW RANDALLIA OUTPATIENT PHARMACY
CAH151310-00 Parkview Wabash Hospital, Inc
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Covered Entity Details
Entity Name
Parkview Wabash Hospital, Inc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151310-00
Entity Address
10 John Kissinger Drive
WABASH, IN 46992-1914
Medicare Provider Number
151310
Participating Start Date
8/12/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
PARKVIEW RANDALLIA OUTPATIENT PHARMACY
Pharmacy Address
2200 RANDALLIA DR
FORT WAYNE, IN 46805
Pharmacy Comments
Contract Details
Approval Date
7/9/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/7/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael P. Browning, Senior Vice President and Chief Financial Officer
(260) 373-8407
Contract Pharmacy Representative
Anthony Scott, Director
(260) 373-3464
Signed By Date
7/9/2015
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