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NEBRASKA CVS PHARMACY, L.L.C.
DSH280013 THE NEBRASKA MEDICAL CENTER
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Covered Entity Details
Entity Name
THE NEBRASKA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH280013
Entity Address
989200 Nebraska Medical Center
Omaha, NE 68198
Medicare Provider Number
280013
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
NEBRASKA CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY # 3085
1701 GALVIN ROAD S.
BELLEVUE, NE 68005
Pharmacy Comments
Contract Details
Approval Date
1/9/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/26/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Stephanie Daubert, CFO
(402) 552-2889
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
1/9/2015
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