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GIANT PHARMACY #159
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
GIANT PHARMACY #159
Pharmacy Address
3757 OLD COURT RD
PIKESVILLE, MD 21208
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/8/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mitchell Gardner Lomax, CFO
(667) 234-2926
Contract Pharmacy Representative
GIANT FOOD
KELLY SHANAHAN, DISTRICT PHARMACY MANAGER
(240) 461-2982
Signed By Date
10/15/2021
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