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MARTIN'S PHARMACY #6107
DSH210001 MERITUS MEDICAL CENTER
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Covered Entity Details
Entity Name
MERITUS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210001
Entity Address
11116 MEDICAL CAMPUS ROAD
HAGERSTOWN, MD 21742
Medicare Provider Number
210001
Participating Start Date
7/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
MARTIN'S PHARMACY #6107
Pharmacy Address
901 FOXCROFT AVENUE
MARTINSBURG, WV 25401
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom T Chan, CFO
(301) 790-8101
Contract Pharmacy Representative
The Giant Company
Nick Koch, Regional Pharmacy Manager
(484) 655-0805
Signed By Date
7/14/2021
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