Contract Pharmacy Details

MEDSTAR PHARMACY STORE # 12
DSH210062 MEDSTAR SOUTHERN MARYLAND HOSPITAL C

Covered Entity Details

Entity Name

MEDSTAR SOUTHERN MARYLAND HOSPITAL C

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH210062

Entity Address

7503 SURRATTS ROAD
CLINTON, MD 20735

Medicare Provider Number

210062

Participating Start Date

10/1/2015

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

MEDSTAR PHARMACY STORE # 12

Pharmacy Address

9000 FRANKLIN SQUARE DR
ROSEDALE, MD 21237-3901

Pharmacy Comments

Contract Details

Approval Date

4/13/2020

Contract Begin Date

7/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2021
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Christine R Wray, President
(301) 877-4530

Contract Pharmacy Representative

MedStar Health
Bonnie Levin, AVP, Pharmacy Services
(410) 772-6773

Signed By Date

4/13/2020

340B Drug Pricing Program Database