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GIANT PHARMACY 166
DSH210034 HARBOR HOSPITAL INC.
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Covered Entity Details
Entity Name
HARBOR HOSPITAL INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210034
Entity Address
3001 SOUTH HANOVER STREET
BALTIMORE, MD 21225
Medicare Provider Number
210034
Participating Start Date
10/1/2003
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
GIANT PHARMACY 166
Pharmacy Address
4622 WILKENS AVE
BALTIMORE, MD 21229
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Deana Stout, VP FINANCE
(410) 554-2228
Contract Pharmacy Representative
GIANT FOOD
KELLY SHANAHAN, DISTRICT PHARMACY MANAGER
(240) 461-2982
Signed By Date
1/15/2025
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