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COMMUNITY PHARMACY
SCH150072-00 MEMORIAL HOSPITAL LOGANSPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL LOGANSPORT
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH150072-00
Entity Address
1101 MICHIGAN AVENUE
LOGANSPORT, IN 46947
Medicare Provider Number
150072
Participating Start Date
7/1/2016
Last Recertification Date
9/19/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
COMMUNITY PHARMACY
Pharmacy Address
COMMUNITY PHARMACY
1201 MICHIGAN AVE STE 100
LOGANSPORT, IN 46947
Pharmacy Comments
Contract Details
Approval Date
5/12/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Beth Jump, COO
(574) 753-1409
Contract Pharmacy Representative
Community Pharmacy
Angela Bowen, Chief Pharmacist
(574) 753-1326
Signed By Date
5/12/2016
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