Contract Pharmacy Details

MOUNT CARMEL PHARMACY
DSH360012 ST. ANN'S HOSP OF COLUMBUS INC,

Covered Entity Details

Entity Name

ST. ANN'S HOSP OF COLUMBUS INC,

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH360012

Entity Address

500 SOUTH CLEVELAND AVE
WESTERVILLE, OH 43081-0000

Medicare Provider Number

360012

Participating Start Date

1/1/2016

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

MOUNT CARMEL PHARMACY

Pharmacy Address

500 S CLEVELAND AVE RM 1L1003
WESTERVILLE, OH 43081-8971

Pharmacy Comments

Contract Details

Approval Date

1/25/2016

Contract Begin Date

4/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

KEITH T. COLEMAN, SENIOR V.P. OF FINANCE & CFO
(614) 546-4300

Contract Pharmacy Representative

Mount Carmel Health System
Amy Dickson, Regional Chief Pharmacy Officer
(614) 546-1031

Signed By Date

1/25/2016

340B Drug Pricing Program Database