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CYSTIC FIBROSIS SERVICES, LLC
DSH210040 NORTHWEST HOSPITAL CENTER, INC.
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Covered Entity Details
Entity Name
NORTHWEST HOSPITAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210040
Entity Address
5401 OLD COURT ROAD
RANDALLSTOWN, MD 21133
Medicare Provider Number
210040
Participating Start Date
10/1/2015
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
7/17/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leslie Simmons, Interim President
(410) 601-7346
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/17/2019
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