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TUFTS MEDICAL CENTER
DSH220063 THE LOWELL GENERAL HOSPITAL
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Covered Entity Details
Entity Name
THE LOWELL GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220063
Entity Address
295 VARNUM AVENUE
LOWELL, MA 01854
Medicare Provider Number
220063
Participating Start Date
4/1/2004
Last Recertification Date
9/12/2024
Pharmacy Details
Pharmacy Name
TUFTS MEDICAL CENTER
Pharmacy Address
OUTPATIENT PHARMACY
800 WASHINGTON ST
BOX 420
BOSTON, MA 02111-1552
Pharmacy Comments
Contract Details
Approval Date
1/10/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/12/2022
Agreement registered in error
Contacts
Covered Entity Signing Official
William F Wyman, SVP of Operations & Treasurer
(978) 937-6034
Contract Pharmacy Representative
Wellforce
Melissa Ortega, Ex Dir Amb Pharmacy
(617) 636-2844
Signed By Date
1/10/2022
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