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WHITLEY MEMORIAL HOSPITAL
CAH151323-00 COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.
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Covered Entity Details
Entity Name
COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151323-00
Entity Address
207 NORTH TOWNLINE ROAD
LAGRANGE, IN 46761
Medicare Provider Number
151323
Participating Start Date
4/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WHITLEY MEMORIAL HOSPITAL
Pharmacy Address
1260 E STATE ROAD 205
COLUMBIA CITY, IN 46725-9492
Pharmacy Comments
Contract Details
Approval Date
10/26/2012
Contract Begin Date
10/26/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/20/2015
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
Scott Gabriel, COO
(260) 248-9521
Signed By Date
9/3/2012
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