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GIANT PHARMACY #363
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
GIANT PHARMACY #363
Pharmacy Address
1400 MERRITT BLVD.
DUNDALK, MD 21222
Pharmacy Comments
Contract Details
Approval Date
4/11/2025
Contract Begin Date
7/1/2025
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
4/11/2025
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