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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
DSH220010 LAWRENCE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
LAWRENCE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220010
Entity Address
1 GENERAL STREET
LAWRENCE, MA 01841
Medicare Provider Number
220010
Participating Start Date
7/1/2004
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
10/8/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Deborah J. Wilson, CFO
(978) 683-4000 Ext: 2004
Contract Pharmacy Representative
Lawrence General Hospital
Timothy Keaney, Pharmacy Director
(978) 683-4000 Ext: 2247
Signed By Date
10/8/2020
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