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CONNECTICUT CVS PHARMACY, L.L.C.
DSH070031 THE GRIFFIN HOSPITAL
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Covered Entity Details
Entity Name
THE GRIFFIN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070031
Entity Address
130 DIVISION STREET
DERBY, CT 06418
Medicare Provider Number
070031
Participating Start Date
7/1/2024
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
CONNECTICUT CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY #1044
656 NEW HAVEN AVE
DERBY, CT 06418-2528
Pharmacy Comments
Contract Details
Approval Date
4/19/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alexander Stephen Balko, VP Finance/CFO
(203) 732-7594
Contract Pharmacy Representative
Griffin Hospital
Lisa Jean Jaser, Director of Pharmacy
(203) 732-7311
Signed By Date
4/15/2024
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