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BOSTON MEDICAL CENTER PHARMACY AT SHAPIR
DSH220063 THE LOWELL GENERAL HOSPITAL
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Covered Entity Details
Entity Name
THE LOWELL GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220063
Entity Address
295 VARNUM AVENUE
LOWELL, MA 01854
Medicare Provider Number
220063
Participating Start Date
4/1/2004
Last Recertification Date
9/12/2024
Pharmacy Details
Pharmacy Name
BOSTON MEDICAL CENTER PHARMACY AT SHAPIR
Pharmacy Address
725 ALBANY ST
PHARMACY
BOSTON, MA 02118-2526
Pharmacy Comments
Contract Details
Approval Date
10/7/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
William F Wyman, SVP of Operations & Treasurer
(978) 937-6034
Contract Pharmacy Representative
BMC
Alexander Pham, Pharmacy Director
(617) 638-5854
Signed By Date
10/7/2019
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