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MEIJER STORES LIMITED PARTNERSHIP
DSH360174 UPPER VALLEY MEDICAL CENTER
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Covered Entity Details
Entity Name
UPPER VALLEY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360174
Entity Address
3130 N. COUNTY ROAD 25 A
TROY, OH 45373
Medicare Provider Number
360174
Participating Start Date
1/1/2016
Last Recertification Date
11/29/2017
Entity Termination Date
7/1/2018
Pharmacy Details
Pharmacy Name
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
1/15/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Timothy Snider, VP Finance
(937) 440-4558
Contract Pharmacy Representative
Meijer
Jeff Romano, Hospital Programs
(616) 791-3171
Signed By Date
1/15/2016
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