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AVELLA OF COLUMBUS
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
AVELLA OF COLUMBUS
Pharmacy Address
4830 KNIGHTSBRIDGE BLVD STE C
COLUMBUS, OH 43214-2300
Pharmacy Comments
Contract Details
Approval Date
10/13/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michelle Waggoner, CEO
(419) 542-5566
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
10/13/2015
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