Contract Pharmacy Details

PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390045 WILLIAMSPORT HOSPITAL & MEDICAL CTR

Covered Entity Details

Entity Name

WILLIAMSPORT HOSPITAL & MEDICAL CTR

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH390045

Entity Address

700 HIGH STREET
WILLIAMSPORT, PA 17701

Medicare Provider Number

390045

Participating Start Date

4/1/2023

Last Recertification Date

8/24/2023

Entity Termination Date

10/1/2024

Pharmacy Details

Pharmacy Name

PENNSYLVANIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 01610
201 MUNCY CREEK BLVD.
MUNCY, PA 17756

Pharmacy Comments

Contract Details

Approval Date

10/16/2023

Contract Begin Date

1/1/2024

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Roger C Yost, CFO, North-Central PA Region
(570) 321-3175

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/16/2023

340B Drug Pricing Program Database