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PENNSYLVANIA CVS PHARMACY, L.L.C.
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
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01913
1405 SOUTH 10TH STREET
PHILADELPHIA, PA 19147
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
NEIL G. LUBARSKY, SR VP FOR FINANCE
(215) 955-9993
Contract Pharmacy Representative
CVS Health
Jaclyn Parfitt, 340B Operations Manager
(401) 770-6467
Signed By Date
10/17/2016
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