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CVS INDIANA
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
CVS INDIANA
Pharmacy Address
7590 EMPIRE DR # 116-123
INDIANAPOLIS, IN 46219-1780
Pharmacy Comments
Contract Details
Approval Date
10/17/2014
Contract Begin Date
1/1/2015
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 Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/17/2014
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