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CYSTIC FIBROSIS SERVICES, LLC
DSH390045 WILLIAMSPORT HOSPITAL & MEDICAL CTR
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Covered Entity Details
Entity Name
WILLIAMSPORT HOSPITAL & MEDICAL CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390045
Entity Address
700 HIGH STREET
WILLIAMSPORT, PA 17701
Medicare Provider Number
390045
Participating Start Date
4/1/2023
Last Recertification Date
8/24/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
3/8/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Roger C Yost, CFO, North-Central PA Region
(570) 321-3175
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/13/2023
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