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OHIO CVS STORES, L.L.C.
SCH360197-00 MARY RUTAN HOSPITAL
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Covered Entity Details
Entity Name
MARY RUTAN HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH360197-00
Entity Address
205 E PALMER ROAD
BELLEFONTAINE, OH 43311
Medicare Provider Number
360197
Participating Start Date
9/30/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06178
143 E. SANDUSKY AVE.
BELLEFONTAINE, OH 43311
Pharmacy Comments
Contract Details
Approval Date
11/16/2012
Contract Begin Date
11/16/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ronald Carmin, CFO, VP Financial Services
(937) 599-7001
Contract Pharmacy Representative
CVS
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
9/26/2012
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