Contract Pharmacy Details

PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390001 COMMUNITY MEDICAL CENTER

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 # 01611
1101 MOOSIC ST.
SCRANTON, PA 18505

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

340B Drug Pricing Program Database