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WELLDYNERX LLC
DSH360096 EAST LIVERPOOL CITY HOSPITAL
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Covered Entity Details
Entity Name
EAST LIVERPOOL CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360096
Entity Address
425 WEST FIFTH STREET
EAST LIVERPOOL, OH 43920
Medicare Provider Number
360096
Participating Start Date
7/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WELLDYNERX LLC
Pharmacy Address
DBA HEALTHDYNE PHARMACY
500 EAGLES LANDING DR
LAKELAND, FL 33810
Pharmacy Comments
Contract Details
Approval Date
10/23/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/26/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ken Payne, CFO
(330) 386-2633
Contract Pharmacy Representative
Jeremy Meyer, SVP PBM Operations
(888) 479-2000
Signed By Date
10/23/2015
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