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CVS PHARMACY, INC.
DSH220086AS BETH ISRAEL DEACONESS MEDICAL CENTER
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Covered Entity Details
Entity Name
BETH ISRAEL DEACONESS MEDICAL CENTER
Subdivision Name
MEDICAL CARE CENTER NORTH - OPTOMETRY CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH220086AS
Entity Address
1000 BROADWAY STREET
CHELSEA, MA 02150
Medicare Provider Number
220086
Outpatient Facility Provider Number
Participating Start Date
1/1/2019
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 00746
171 NORTH MAIN STREET
RANDOLPH, MA 02368
Pharmacy Comments
Contract Details
Approval Date
4/21/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Larkin, Chief Operating Officer
(617) 677-7144
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/21/2023
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