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OHIO CVS STORES, L.L.C.
SCH360125-00 Ashtabula County Medical Center
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Covered Entity Details
Entity Name
Ashtabula County Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH360125-00
Entity Address
2420 Lake Avenue
Ashtabula, OH 44004
Medicare Provider Number
360125
Participating Start Date
1/1/2012
Last Recertification Date
9/9/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
OHIO CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04331
380 STATE ST.
CONNEAUT, OH 44030
Pharmacy Comments
Contract Details
Approval Date
7/8/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Donald L. Kepner, Chief Financial Officer
(440) 997-6912
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
7/8/2014
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