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WAL-MART PHARMACY 10-1504
DSH360239 SYCAMORE HOSPITAL
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Covered Entity Details
Entity Name
SYCAMORE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360239
Entity Address
4000 Miamisburg-Centerville Rd
MIAMISBURG, OH 45342
Medicare Provider Number
360239
Participating Start Date
1/1/2017
Last Recertification Date
9/10/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1504
Pharmacy Address
8800 KINGSRIDGE DR
DAYTON, OH 45458
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
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Terrance Michael Burns, Chief Financial Officer
(937) 395-8520
Contract Pharmacy Representative
Fort Hamilton Hospital
Doug Lukens, Director of Pharmacy
(937) 395-5467
Signed By Date
4/13/2018
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