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OHIO CVS STORES, L.L.C.
CAH361319-00 SELBY GENERAL HOSPITAL
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Covered Entity Details
Entity Name
SELBY GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361319-00
Entity Address
1106 COLEGATE DRIVE
MARIETTA, OH 45750
Medicare Provider Number
361319
Participating Start Date
7/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03422
131 3RD ST.
MARIETTA, OH 45750
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/7/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
STEPHEN P. SMITH, PRESIDENT
(740) 568-2040
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
4/14/2014
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