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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390045 WILLIAMSPORT HOSPITAL & MEDICAL CTR
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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 # 04152
5600 WILKINS AVE
PITTSBURGH, PA 15217
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
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