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HOOK-SUPERX, L.L.C.
CAH151320-00 JAY COUNTY HOSPITAL
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Covered Entity Details
Entity Name
JAY COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151320-00
Entity Address
500 W. VOTAW
PORTLAND, IN 47371
Medicare Provider Number
151320
Participating Start Date
1/1/2016
Last Recertification Date
11/3/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
HOOK-SUPERX, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06624
802 N MERIDIAN ST
PORTLAND, IN 47371
Pharmacy Comments
Contract Details
Approval Date
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Don Michael, CFO
(260) 726-7131 Ext: 1018
Contract Pharmacy Representative
CVS Caremark
JACKLYN PARFITT, MANAGER, PAYER RELATIONS
(401) 770-6467
Signed By Date
1/4/2016
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