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CVS STATE CAPITAL, L.L.C.
DSH330090 ARNOT OGDEN MEDICAL CENTER
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Covered Entity Details
Entity Name
ARNOT OGDEN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330090
Entity Address
600 Roe Ave
ELMIRA, NY 14905
Medicare Provider Number
330090
Participating Start Date
10/27/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00959
11 STEEPLE WAY, PO BOX 130
WELLS, ME 04090
Pharmacy Comments
Contract Details
Approval Date
4/16/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark Dworsky, Vice President of Clinical Services
(607) 737-4152
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/16/2020
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