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MARYLAND CVS PHARMACY, L.L.C.
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
MARYLAND CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04411
5501 PARK HEIGHTS AVE
BALTIMORE, MD 21215
Pharmacy Comments
Contract Details
Approval Date
1/3/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Leslie Simmons, Interim President
(410) 601-7346
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/3/2020
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