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CONNECTICUT CVS PHARMACY, L.L.C.
RRC070031-00 THE GRIFFIN HOSPITAL
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Covered Entity Details
Entity Name
THE GRIFFIN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC070031-00
Entity Address
130 DIVISION STREET
DERBY, CT 06418
Medicare Provider Number
070031
Participating Start Date
4/1/2022
Last Recertification Date
9/18/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
CONNECTICUT CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY #1044
656 NEW HAVEN AVE
DERBY, CT 06418-2528
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alexander Stephen Balko, VP Finance/CFO
(203) 732-7594
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/17/2022
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