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MAIN STREET PHARMACY LLC
DSH210011 ST. AGNES HOSPITAL
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Covered Entity Details
Entity Name
ST. AGNES HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210011
Entity Address
900 CATON AVENUE
BALTIMORE, MD 21229
Medicare Provider Number
210011
Participating Start Date
4/1/2016
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
MAIN STREET PHARMACY LLC
Pharmacy Address
CVS/PHARMACY #48271
715 MAIDEN CHOICE LANE
BALTIMORE, MD 21228
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/18/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Mitchell Gardner Lomax, CFO
(667) 234-2926
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/14/2023
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