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CYSTIC FIBROSIS SERVICES, LLC
DSH150011 MARION GENERAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
MARION GENERAL HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150011
Entity Address
441 NORTH WABASH AVENUE
MARION, IN 46952
Medicare Provider Number
150011
Participating Start Date
7/1/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
10/9/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/26/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
STEPHANIE HILTON-SIEBERT, CHIEF ADMINISTRATIVE OFFICER
(765) 660-7007
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/9/2017
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