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KMART PHARMACY #7042
DSH150002 THE METHODIST HOSPITALS
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Covered Entity Details
Entity Name
THE METHODIST HOSPITALS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150002
Entity Address
600 GRANT ST
GARY, IN 46402
Medicare Provider Number
150002
Participating Start Date
4/1/2003
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
KMART PHARMACY #7042
Pharmacy Address
2801 CALUMET AVE
VALPARAISO, IN 46383
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/29/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew Shawn Doyle, President & CEO
(219) 886-4608
Contract Pharmacy Representative
Methodist
Jacquelyn Ivankovic, Associate Director of Pharmacy
(219) 738-5807
Signed By Date
10/16/2017
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