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BAYSIDE PHARMACY & PHYSICIAN
DSH390063 UPMC HAMOT
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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
BAYSIDE PHARMACY & PHYSICIAN
Pharmacy Address
SUPPLY COMPANY
300 STATE STREET
SUITE 102
ERIE, PA 16507
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brad N Dinger, CFO
(814) 877-3739
Contract Pharmacy Representative
Bayside Pharmacy
Neil Mehta, Pharmacy Manager
(814) 351-0026
Signed By Date
1/15/2021
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