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CVS PHARMACY, INC.
DSH220086D BETH ISRAEL DEACONESS MEDICAL CENTER
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Covered Entity Details
Entity Name
BETH ISRAEL DEACONESS MEDICAL CENTER
Subdivision Name
West Campus
Type
Disproportionate Share Hospital
340B ID
DSH220086D
Entity Address
ONE DEACONESS ROAD
BOSTON, MA 02215
Medicare Provider Number
220086
Outpatient Facility Provider Number
Participating Start Date
4/1/2010
Last Recertification Date
9/7/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
CVS PHARMACY # 17059
36 FURLONG DR
REVERE, MA 02151
Pharmacy Comments
Contract Details
Approval Date
4/21/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
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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