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VIRGINIA CVS PHARMACY, L.L.C.
DSH490022 MARY WASHINGTON HOSPITAL
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Covered Entity Details
Entity Name
MARY WASHINGTON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490022
Entity Address
1001 SAM PERRY BLVD
FREDERICKSBURG, VA 22401
Medicare Provider Number
490022
Participating Start Date
7/1/2024
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
VIRGINIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01539
10805 TIDEWATER TRAIL
FREDERICKSBURG, VA 22408
Pharmacy Comments
Contract Details
Approval Date
7/10/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sean Timothy Barden, Executive VP & CFO
(540) 741-1494
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/10/2024
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