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ASCENSION RX 1001
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
ASCENSION RX 1001
Pharmacy Address
ASCENSION PHARMACY SERVICES, LLC.
7701 METROPOLIS DR STE 200B
AUSTIN, TX 78744-3125
Pharmacy Comments
Contract Details
Approval Date
7/18/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mitchell Gardner Lomax, CFO
(667) 234-2926
Contract Pharmacy Representative
ASCENSION RX 1001
ERICA WRIGHT, PHARMACY MANAGER
(833) 633-7279
Signed By Date
7/18/2021
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