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LINESVILLE PHARMACY
DSH390113 Meadville Medical Center
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Covered Entity Details
Entity Name
Meadville Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390113
Entity Address
751 Liberty Street
Meadville, PA 16335
Medicare Provider Number
390113
Participating Start Date
7/1/2013
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
LINESVILLE PHARMACY
Pharmacy Address
LINESVILLE PHARMACY INC
123 W ERIE ST
LINESVILLE, PA 16424
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Renato J. Suntay, Chief Financial Officer
(814) 333-5030
Contract Pharmacy Representative
Bretton C. Wallberg, Owner
(724) 373-8533
Signed By Date
7/15/2013
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