Contract Pharmacy Details

PARKSIDE PHARMACY
DSH150104 WITHAM MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

WITHAM MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH150104

Entity Address

2605 N. LEBANON STREET
LEBANON, IN 46052

Medicare Provider Number

150104

Participating Start Date

5/19/2020

Last Recertification Date

9/12/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

PARKSIDE PHARMACY

Pharmacy Address

1639 N LEBANON ST
LEBANON, IN 46052

Pharmacy Comments

Contract Details

Approval Date

1/10/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

George Pogas, SR VP of Finance/CFO
(765) 485-8102

Contract Pharmacy Representative

Cowan Drugs
john Cowan, President
(765) 482-0180

Signed By Date

1/10/2014