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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390118 BRADFORD REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BRADFORD REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390118
Entity Address
116-56 INTERSTATE PARKWAY
BRADFORD, PA 16701
Medicare Provider Number
390118
Participating Start Date
7/1/2005
Last Recertification Date
11/6/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04270
10 DAVIS ST
BRADFORD, PA 16701
Pharmacy Comments
Contract Details
Approval Date
1/12/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Richard G. Braun Jr., SVP Finance and CFO
(716) 375-6190
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
1/12/2015
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