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GIANT PHARMACY 166
DSH210011 ST. AGNES HOSPITAL
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Covered Entity Details
Entity Name
ST. AGNES HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210011
Entity Address
900 CATON AVENUE
BALTIMORE, MD 21229
Medicare Provider Number
210011
Participating Start Date
4/1/2016
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
GIANT PHARMACY 166
Pharmacy Address
4622 WILKENS AVE
BALTIMORE, MD 21229
Pharmacy Comments
Contract Details
Approval Date
1/6/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mitchell Gardner Lomax, CFO
(667) 234-2926
Contract Pharmacy Representative
The Giant Company
Nick Koch, Regional Pharmacy Manager
(484) 655-0805
Signed By Date
1/6/2025
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