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BRIOVARX OF MAINE INC
DSH390142 ALBERT EINSTEIN MEDICAL CENTER
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Covered Entity Details
Entity Name
ALBERT EINSTEIN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390142
Entity Address
5501 OLD YORK ROAD
PHILADELPHIA, PA 19141
Medicare Provider Number
390142
Participating Start Date
1/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
7/6/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
GERARD BLANEY, CHIEF FINANCIAL OFFICER
(215) 456-6020
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
7/6/2017
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