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BROWN UNIVERSITY HEALTH PHARMACY NO 003
STD02904 The Miriam Hospital
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Covered Entity Details
Entity Name
The Miriam Hospital
Subdivision Name
Immunology Center
Type
Sexually Transmitted Diseases
340B ID
STD02904
Entity Address
180 Corliss St.
Suite F
Providence, RI 02904
Grant Number
NH25PS0051600501
Participating Start Date
1/1/2015
Last Recertification Date
5/14/2024
Pharmacy Details
Pharmacy Name
BROWN UNIVERSITY HEALTH PHARMACY NO 003
Pharmacy Address
180 CORLISS ST STE A
PROVIDENCE, RI 02904
Pharmacy Comments
Contract Details
Approval Date
7/11/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mary Wakefield, Senior VP and CFO
(401) 444-7093
Contract Pharmacy Representative
Brown University Health
CHRISTINE COLLINS, SVP, Pharmacy & Periop, Chief Pharmacy Officer
(401) 444-4434
Signed By Date
7/11/2019
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