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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH330103 OLEAN GENERAL HOSPITAL
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Covered Entity Details
Entity Name
OLEAN GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330103
Entity Address
515 MAIN STREET
OLEAN, NY 14760
Medicare Provider Number
330103
Participating Start Date
10/1/2019
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04270
10 DAVIS ST
BRADFORD, PA 16701
Pharmacy Comments
Contract Details
Approval Date
8/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard G. Braun Jr., SVP Finance and CFO
(716) 375-6190
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/11/2019
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