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FRUTH PHARMACY OF OHIO INC
CAH361320-00 HOLZER MEDICAL CENTER-JACKSON
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Covered Entity Details
Entity Name
HOLZER MEDICAL CENTER-JACKSON
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361320-00
Entity Address
500 BURLINGTON ROAD
JACKSON, OH 45640
Medicare Provider Number
361320
Participating Start Date
4/1/2011
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
FRUTH PHARMACY OF OHIO INC
Pharmacy Address
FRUTH PHARMACY #3
2991 STATE ROUTE 160
GALLIPOLIS, OH 45631
Pharmacy Comments
Contract Details
Approval Date
10/16/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher Meyer, Chief Medical Officer
(740) 446-5051
Contract Pharmacy Representative
Fruth Pharmacy
Tom Willoughby, Chief Financial Officer
(304) 675-1612 Ext: 163
Signed By Date
10/16/2015
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