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INOVA PHARMACY PLUS AT INOVA FAIR OAKS
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
INOVA PHARMACY PLUS AT INOVA FAIR OAKS
Pharmacy Address
3600 JOSEPH SIEWICK DR
FAIRFAX, VA 22033-1709
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
1/26/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
anuj steve narang, President
(480) 737-1397
Contract Pharmacy Representative
Inova Pharmacy Plus at Inova Fair Oaks
Naila Khan, Retail Pharmacy Manager PIC
(703) 391-3080
Signed By Date
1/14/2021
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