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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390027 TEMPLE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
TEMPLE UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390027
Entity Address
3401 North Broad Street
PHILADELPHIA, PA 19140
Medicare Provider Number
390027
Participating Start Date
1/1/2004
Last Recertification Date
8/17/2024
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 07184
7720 BUSTLETON AVE
PHILADELPHIA, PA 19152
Pharmacy Comments
Contract Details
Approval Date
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Abhinav Rastogi, President & C.E.O
(215) 707-4299
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/17/2023
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