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PROCARE PHARMACY, L.L.C.
DSH210040 NORTHWEST HOSPITAL CENTER, INC.
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Covered Entity Details
Entity Name
NORTHWEST HOSPITAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210040
Entity Address
5401 OLD COURT ROAD
RANDALLSTOWN, MD 21133
Medicare Provider Number
210040
Participating Start Date
10/1/2015
Last Recertification Date
8/30/2024
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
7/6/2021
Contract Begin Date
8/19/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leslie Simmons, Interim President
(410) 601-7346
Contract Pharmacy Representative
CVS Health
Kristina Tower, Senior Account Manager
(646) 771-7606
Signed By Date
7/6/2021
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