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MEDSTAR PHARMACY STORE # 12
DSH210024 UNION MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
UNION MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210024
Entity Address
201 E UNIVERSITY PARKWAY
BALTIMORE, MD 21218
Medicare Provider Number
210024
Participating Start Date
10/1/2010
Last Recertification Date
8/23/2024
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
Contract Termination Date
Termination Reason
7/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Deana Stout, VP FINANCE
(410) 554-2228
Contract Pharmacy Representative
MedStar Health
Bonnie Levin, AVP, Pharmacy Services
(410) 772-6773
Signed By Date
4/15/2020
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