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FACTOR ONE SOURCE PHARMACY LLC
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
FACTOR ONE SOURCE PHARMACY LLC
Pharmacy Address
DBA INFUCARE RX OF MD
217 GLENN ST STE 300
CUMBERLAND, MD 21502-2590
Pharmacy Comments
Contract Details
Approval Date
7/6/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Abhinav Rastogi, President & C.E.O
(215) 707-4299
Contract Pharmacy Representative
Infucare
Mark Milburn, 340B Director
(877) 828-3940
Signed By Date
7/6/2023
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