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GIANT EAGLE PHARMACY #4089
CAH361302-00 TRINITY HOSPITAL TWIN CITY
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Covered Entity Details
Entity Name
TRINITY HOSPITAL TWIN CITY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361302-00
Entity Address
819 N 1st STREET
DENNISON, OH 44621-1003
Medicare Provider Number
361302
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
GIANT EAGLE PHARMACY #4089
Pharmacy Address
515 UNION AVENUE
DOVER, OH 44622
Pharmacy Comments
Contract Details
Approval Date
1/18/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
HALLI SELL, CONTROLLER
(740) 922-7450 Ext: 2180
Contract Pharmacy Representative
Giant Eagle, Inc.
Mike Bianco, Senior Pharmacy Manager
(412) 967-3718
Signed By Date
1/18/2016
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