Contract Pharmacy Details

MEDSTAR PHARMACY STORE # 12
DSH210056 GOOD SAMARITAN HOSPITAL

Covered Entity Details

Entity Name

GOOD SAMARITAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH210056

Entity Address

5601 LOCH RAVEN BLVD
BALTIMORE, MD 21239

Medicare Provider Number

210056

Participating Start Date

4/1/2018

Last Recertification Date

8/22/2024

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

340B Drug Pricing Program Database