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AFFILIATED HEALTH SERVICES, INC.
DSH210011 ST. AGNES HOSPITAL
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Covered Entity Details
Entity Name
ST. AGNES HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210011
Entity Address
900 CATON AVENUE
BALTIMORE, MD 21229
Medicare Provider Number
210011
Participating Start Date
4/1/2016
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
AFFILIATED HEALTH SERVICES, INC.
Pharmacy Address
DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334
Pharmacy Comments
Contract Details
Approval Date
7/18/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/23/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mitchell Gardner Lomax, CFO
(667) 234-2926
Contract Pharmacy Representative
Ascension Michigan Pharmacy
Suzanne Noe, Pharmacist
(248) 865-3770
Signed By Date
7/18/2021
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