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RHODE ISLAND CVS PHARMACY, L.L.C.
STD02904 The Miriam Hospital
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Covered Entity Details
Entity Name
The Miriam Hospital
Subdivision Name
Immunology Center
Type
Sexually Transmitted Diseases
340B ID
STD02904
Entity Address
180 Corliss St.
Suite F
Providence, RI 02904
Grant Number
NH25PS0051600501
Participating Start Date
1/1/2015
Last Recertification Date
5/14/2024
Pharmacy Details
Pharmacy Name
RHODE ISLAND CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04796
960 BROAD STREET
PROVIDENCE, RI 02905
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mary Wakefield, Senior VP and CFO
(401) 444-7093
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2020
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