Contract Pharmacy Details

PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390174 THOMAS JEFFERSON UNIVERSITY HOSPITAL

Covered Entity Details

Entity Name

THOMAS JEFFERSON UNIVERSITY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH390174

Entity Address

111 South 11th Street
Philadelphia, PA 19107

Medicare Provider Number

390174

Participating Start Date

4/1/2006

Last Recertification Date

9/8/2024

Pharmacy Details

Pharmacy Name

PENNSYLVANIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 02114
6562-68 HAVERFORD AVENUE
PHILADELPHIA, PA 19151

Pharmacy Comments

Contract Details

Approval Date

4/14/2020

Contract Begin Date

7/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2021
Pharmacy closed

Contacts

Covered Entity Signing Official

Andrew Nathans, Vice president Finance, TJUH Inc.
(215) 955-6599

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

4/14/2020

340B Drug Pricing Program Database