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MEDSTAR PHARMACY STORE # 12
SCH210028-00 ST. MARYS HOSPITAL
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Covered Entity Details
Entity Name
ST. MARYS HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH210028-00
Entity Address
25500 POINT LOOKOUT RD
LEONARDTOWN, MD 20650
Medicare Provider Number
210028
Participating Start Date
10/1/2018
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
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEPHEN THEODORE MICHAELS, COO/CMO
(301) 475-6082
Contract Pharmacy Representative
MedStar Health
Bonnie Levin, AVP, Pharmacy Services
(410) 772-6773
Signed By Date
4/15/2020
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