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WAL-MART PHARMACY 10-1463
DSH360360 SOIN MEDICAL CENTER
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Covered Entity Details
Entity Name
SOIN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360360
Entity Address
3535 PENTAGON PARK BOULEVARD
BEAVERCREEK, OH 45431
Medicare Provider Number
360360
Participating Start Date
10/1/2019
Last Recertification Date
9/7/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1463
Pharmacy Address
70 HOSPITALITY DRIVE
XENIA, OH 45385
Pharmacy Comments
Contract Details
Approval Date
4/13/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ronald D Connovich, Soin Chief Finanacil Officer
(937) 352-2240
Contract Pharmacy Representative
Soin Medical Center
Jill Hope, Pharmacy Manager
(937) 702-4771
Signed By Date
4/13/2018
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