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COMMCARE PHARMACY-FTL, LLC
DSH360112J MERCY HEALTH - ST. VINCENT MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY HEALTH - ST. VINCENT MEDICAL CENTER
Subdivision Name
Mercy Health - Perrysburg Cancer Center
Type
Disproportionate Share Hospital
340B ID
DSH360112J
Entity Address
12623 Eckel Junction Road
Perrysburg, OH 43551
Medicare Provider Number
360112
Outpatient Facility Provider Number
Participating Start Date
10/1/2013
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
COMMCARE PHARMACY-FTL, LLC
Pharmacy Address
855 SW 78TH AVE STE C100
PLANTATION, FL 33324-3223
Pharmacy Comments
Contract Details
Approval Date
4/14/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/6/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Donald E. Kline, Chief Financial Officer, Northern Division
(330) 884-7118
Contract Pharmacy Representative
Commcare
Bob Raffalo, VP Specialty Pharmacy Operations
(954) 284-2384
Signed By Date
4/14/2015
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