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CYSTIC FIBROSIS SERVICES, LLC
DSH210019 TIDALHEALTH PENINSULA REGIONAL INC
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Covered Entity Details
Entity Name
TIDALHEALTH PENINSULA REGIONAL INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210019
Entity Address
100 EAST CARROLL STREET
SALISBURY, MD 21801
Medicare Provider Number
210019
Participating Start Date
3/15/2022
Last Recertification Date
8/15/2024
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
7/2/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bruce Ritchie, CFO
(410) 543-7298
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/2/2018
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