Contract Pharmacy Details

OHIO CVS STORES, L.L.C.
SCH360109-00 COSHOCTON CTY MEM HOSP

Covered Entity Details

Entity Name

COSHOCTON CTY MEM HOSP

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH360109-00

Entity Address

1460 ORANGE STREET
COSHOCTON, OH 43812-2229

Medicare Provider Number

360109

Participating Start Date

10/1/2017

Last Recertification Date

11/7/2017

Entity Termination Date

10/1/2018

Pharmacy Details

Pharmacy Name

OHIO CVS STORES, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03455
200 SOUTH SECOND STREET
COSHOCTON, OH 43812

Pharmacy Comments

Contract Details

Approval Date

12/2/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/1/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Scott Silvestri, CFO
(740) 623-4144

Contract Pharmacy Representative

CVS
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762

Signed By Date

11/20/2013

340B Drug Pricing Program Database