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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390174 THOMAS JEFFERSON UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390174
Entity Address
111 South 11th Street
Philadelphia, PA 19107
Medicare Provider Number
390174
Participating Start Date
4/1/2006
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY # 10896
629 WEST LANCASTER AVE
WAYNE, PA 19087
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Walter Wyatt, VP-Finance
(215) 254-3254
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2025
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