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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390201 POCONO MEDICAL CENTER
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Covered Entity Details
Entity Name
POCONO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390201
Entity Address
206 EAST BROWN STREET
EAST STROUDSBURG, PA 18301-3006
Medicare Provider Number
390201
Participating Start Date
3/15/2022
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03998
5122 MILFORD RD.
EAST STROUDSBURG, PA 18302
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stephen Patrick Molitoris, Vice President
(484) 884-0974
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2021
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