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CONNECTICUT CVS PHARMACY, L.L.C.
DSH220065 BAYSTATE NOBLE HOSPITAL
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Covered Entity Details
Entity Name
BAYSTATE NOBLE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220065
Entity Address
115 WEST SILVER STREET
WESTFIELD, MA 01086
Medicare Provider Number
220065
Participating Start Date
7/1/2019
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
CONNECTICUT CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16603
90 ELM ST
ENFIELD, CT 06082
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/8/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dennis Chalke, Sr. VP Finance & Community Hospitals/CFO & Treasurer
(413) 794-3290
Contract Pharmacy Representative
CVS
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
7/15/2019
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