Contract Pharmacy Details

GIANT EAGLE PHARMACY #4237
DSH390063 UPMC HAMOT

Covered Entity Details

Entity Name

UPMC HAMOT

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH390063

Entity Address

201 STATE STREET
ERIE, PA 16550

Medicare Provider Number

390063

Participating Start Date

4/1/2015

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

GIANT EAGLE PHARMACY #4237

Pharmacy Address

2067 INTERCHANGE ROAD
ERIE, PA 16509

Pharmacy Comments

Contract Details

Approval Date

7/10/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/13/2021
Agreement registered in error

Contacts

Covered Entity Signing Official

Brad N Dinger, CFO
(814) 877-3739

Contract Pharmacy Representative

GIANT EAGLE
Mike Bianco, President & CEO
(412) 967-3718

Signed By Date

7/10/2020