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CYSTIC FIBROSIS SERVICES
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
CYSTIC FIBROSIS SERVICES
Pharmacy Address
CYSTIC FIBROSIS SERVICES, INC
10530 JOHN W ELLIOTT DR, STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/10/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/9/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeanne Wickens, CFO
(260) 373-8407
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/10/2017
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