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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390001 COMMUNITY MEDICAL CENTER
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Covered Entity Details
Entity Name
COMMUNITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390001
Entity Address
1800 MULBERRY STREET
SCRANTON, PA 18510
Medicare Provider Number
390001
Participating Start Date
4/1/2022
Last Recertification Date
9/3/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01593
110 GREEN RIDGE STREET
SCRANTON, PA 18509
Pharmacy Comments
Contract Details
Approval Date
3/14/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ron Beer, Chief Admiistrative Officer
(570) 808-5380
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
3/12/2022
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