Contract Pharmacy Details

HOOK-SUPERX, L.L.C.
DSH150021 Parkview Hospital

Covered Entity Details

Entity Name

Parkview Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH150021

Entity Address

11109 PARKVIEW PLAZA DRIVE
FORT WAYNE, IN 46845

Medicare Provider Number

150021

Participating Start Date

10/1/2015

Last Recertification Date

8/14/2024

Pharmacy Details

Pharmacy Name

HOOK-SUPERX, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06479
1703 CARROLL RD.
FORT WAYNE, IN 46845

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