Contract Pharmacy Details

HOOK-SUPERX, L.L.C.
DSH150101 WHITLEY MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

WHITLEY MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH150101

Entity Address

1260 E STATE ROAD 205
COLUMBIA CITY, IN 46725-9492

Medicare Provider Number

150101

Participating Start Date

10/1/2015

Last Recertification Date

8/15/2018

Entity Termination Date

7/1/2019

Pharmacy Details

Pharmacy Name

HOOK-SUPERX, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06509
2802 EAST STATE BOULEVARD
FORT WAYNE, IN 46805

Pharmacy Comments

Contract Details

Approval Date

10/15/2015

Contract Begin Date

1/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/10/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Stanton Risser, Assoc Chief Financial Officer
(260) 266-9313

Contract Pharmacy Representative

CVS
Christian Reid, 340B Program Director, CVS Pharmacy
(401) 770-2118

Signed By Date

10/15/2015

340B Drug Pricing Program Database