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JEFFERSON APOTHECARY
DSH390174 THOMAS JEFFERSON UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390174
Entity Address
111 South 11th Street
Philadelphia, PA 19107
Medicare Provider Number
390174
Participating Start Date
4/1/2006
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
JEFFERSON APOTHECARY
Pharmacy Address
111 S 11TH ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/21/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/13/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
NEIL G. LUBARSKY, SR VP FOR FINANCE
(215) 955-9993
Contract Pharmacy Representative
Thomas Jefferson University Hospitals
Bill Balas, Assistant Director of Outpatient Pharmacy
(215) 955-9218
Signed By Date
4/21/2016
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