Contract Pharmacy Details

DIPLOMAT SPECIALTY PHARMACY
DSH490063 INOVA FAIRFAX HOSPITAL

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

DIPLOMAT SPECIALTY PHARMACY

Pharmacy Address

4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683

Pharmacy Comments

04/09/2012 update address and name (added suite)

Contract Details

Approval Date

4/16/2021

Contract Begin Date

4/21/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2022
Ownership change

Contacts

Covered Entity Signing Official

anuj steve narang, President
(480) 737-1397

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

4/16/2021

340B Drug Pricing Program Database