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INOVA RETAIL AND SPECIALTY PHARMACY
DSH490063 INOVA FAIRFAX HOSPITAL
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Covered Entity Details
Entity Name
INOVA FAIRFAX HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490063
Entity Address
3300 Gallows Road
Falls Church, VA 22042
Medicare Provider Number
490063
Participating Start Date
10/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
INOVA RETAIL AND SPECIALTY PHARMACY
Pharmacy Address
3901 STONECROFT BLVD STE A1400
CHANTILLY, VA 20151
Pharmacy Comments
Contract Details
Approval Date
4/10/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Susan Carroll, CEO
(703) 776-3050
Contract Pharmacy Representative
Inova Health System
Mariam Mirkhel, Pharmacy Manager/PIC
(571) 472-1100
Signed By Date
4/10/2019
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