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RHODE ISLAND CVS PHARMACY, L.L.C.
DSH410007 RHODE ISLAND HOSPITAL
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Covered Entity Details
Entity Name
RHODE ISLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410007
Entity Address
593 EDDY STREET
PROVIDENCE, RI 02903
Medicare Provider Number
410007
Participating Start Date
4/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
RHODE ISLAND CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00642
767 WARWICK AVENUE
WARWICK, RI 02888
Pharmacy Comments
Contract Details
Approval Date
10/26/2012
Contract Begin Date
10/26/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mary Wakefield, Senior VP and CFO
(401) 444-7093
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
9/28/2012
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