Contract Pharmacy Details

HOOK-SUPERX, L.L.C.
DSH150002 THE METHODIST HOSPITALS

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

HOOK-SUPERX, L.L.C.

Pharmacy Address

DBA CVS/PHARMACY #10925
3612 VILLAGE COURT
GARY, IN 46408

Pharmacy Comments

Contract Details

Approval Date

12/6/2017

Contract Begin Date

12/7/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/18/2019
Pharmacy closed

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

12/6/2017

340B Drug Pricing Program Database