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HICKSVILLE PHARMACY AND HOME MEDICAL, IN
CAH361301-00 Community Memorial Hospital
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Covered Entity Details
Entity Name
Community Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361301-00
Entity Address
208 Columbus Street
Hicksville, OH 43526
Medicare Provider Number
361301
Participating Start Date
1/1/2014
Last Recertification Date
8/31/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
HICKSVILLE PHARMACY AND HOME MEDICAL, IN
Pharmacy Address
HICKSVILLE PHARMACY & HOME MEDICAL INC
116 E HIGH ST
HICKSVILLE, OH 43526
Pharmacy Comments
Contract Details
Approval Date
1/14/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mel Fahs, CEO
(419) 542-7140
Contract Pharmacy Representative
Jon Myers, Owner
(419) 542-6218
Signed By Date
1/14/2014
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