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PROCARE PHARMACY, L.L.C.
DSH210056 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210056
Entity Address
5601 LOCH RAVEN BLVD
BALTIMORE, MD 21239
Medicare Provider Number
210056
Participating Start Date
4/1/2018
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
4/10/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Deana Stout, VP FINANCE
(410) 554-2228
Contract Pharmacy Representative
Caremark L.L.C.
Christian reid, 340b Program Director
(401) 770-2118
Signed By Date
4/10/2021
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