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FILLMORE PHARMACY
CAH361329-00 WYANDOT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WYANDOT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361329-00
Entity Address
885 N Sandusky Ave
UPPER SANDUSKY, OH 43351
Medicare Provider Number
361329
Participating Start Date
8/19/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
FILLMORE PHARMACY
Pharmacy Address
119 SOUTH SYCAMORE AVE
P O BOX 107
SYCAMORE, OH 44882
Pharmacy Comments
Contract Details
Approval Date
3/5/2012
Contract Begin Date
3/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2021
Ownership change
Contacts
Covered Entity Signing Official
TY SHAULL, COO
(419) 294-4991 Ext: 2263
Contract Pharmacy Representative
Fillmore Pharmacy
Kevin Pelter, Owner
(419) 927-2691
Signed By Date
2/23/2012
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