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EXPRESS SCRIPTS PHARMACY, INC.
DSH490063 INOVA FAIRFAX HOSPITAL
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Covered Entity Details
Entity Name
INOVA FAIRFAX HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490063
Entity Address
3300 Gallows Road
Falls Church, VA 22042
Medicare Provider Number
490063
Participating Start Date
10/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
EXPRESS SCRIPTS PHARMACY, INC.
Pharmacy Address
DBA EXPRESS SCRIPTS
2040 ROUTE 130 NORTH
BURLINGTON, NJ 08016
Pharmacy Comments
Contract Details
Approval Date
10/6/2020
Contract Begin Date
11/9/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
anuj steve narang, President
(480) 737-1397
Contract Pharmacy Representative
Accredo Specialty Pharmacy
Gene McCabe, Lead Director, 340B Client Sales
(615) 943-7500
Signed By Date
10/6/2020
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