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RITE AID OF MARYLAND, INC.
DSH210011 ST. AGNES HOSPITAL
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Covered Entity Details
Entity Name
ST. AGNES HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210011
Entity Address
900 CATON AVENUE
BALTIMORE, MD 21229
Medicare Provider Number
210011
Participating Start Date
4/1/2016
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
RITE AID OF MARYLAND, INC.
Pharmacy Address
RITE AID #2210
1400 SULPHUR SPRING ROAD
BALTIMORE, MD 21227
Pharmacy Comments
Contract Details
Approval Date
1/10/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/27/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Scott Furniss, Senior Vice President / CFO
(667) 234-3130
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
1/10/2019
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