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BRIOVARX OF MASSACHUSETTS, LLC
DSH050017 MERCY GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MERCY GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050017
Entity Address
4001 J STREET
SACRAMENTO, CA 95819
Medicare Provider Number
050017
Participating Start Date
4/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MASSACHUSETTS, LLC
Pharmacy Address
D/B/A BRIOVARX
BLDG 2 - UNIT A
145 BODWELL STREET
AVON, MA 02322
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/30/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bonnie Helen Jenkins, CFO
(916) 453-4459
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/11/2019
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