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MARYLAND CVS PHARMACY, L.L.C.
DSH210056 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210056
Entity Address
5601 LOCH RAVEN BLVD
BALTIMORE, MD 21239
Medicare Provider Number
210056
Participating Start Date
4/1/2018
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
MARYLAND CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05875
6001 HIGH BRIDGE RD.
BOWIE, MD 20720
Pharmacy Comments
Contract Details
Approval Date
7/8/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Deana Stout, VP FINANCE
(410) 554-2228
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/8/2024
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