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TUFTS MEDICINE HOME INFUSION SERVICES
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 MEDICINE HOME INFUSION SERVICES
Pharmacy Address
170 GOVERNORS AVE
MEDFORD, MA 02155
Pharmacy Comments
Contract Details
Approval Date
7/12/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William F Wyman, SVP of Operations & Treasurer
(978) 937-6034
Contract Pharmacy Representative
Tufts Medicine
Keith Thomasset, SVP Pharmacy
(978) 942-2160
Signed By Date
7/12/2022
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