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MEDICAL PARK 11 PHARMACY
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
MEDICAL PARK 11 PHARMACY
Pharmacy Address
11104 PARKVIEW CIRCLE DR
FORT WAYNE, IN 46845-1704
Pharmacy Comments
Contract Details
Approval Date
5/21/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/7/2016
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
Anthony Scott, Director
(260) 373-3464
Signed By Date
5/21/2015
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