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GIANT EAGLE PHARMACY #2404
DSH390114B UPMC Magee-Womens Hospital
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Covered Entity Details
Entity Name
UPMC Magee-Womens Hospital
Subdivision Name
MAGEE AT CLAIRTON
Type
Disproportionate Share Hospital
340B ID
DSH390114B
Entity Address
559 MILLER AVENUE
CLAIRTON, PA 15025
Medicare Provider Number
390114
Outpatient Facility Provider Number
Participating Start Date
4/1/2003
Last Recertification Date
8/25/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
GIANT EAGLE PHARMACY #2404
Pharmacy Address
200 ALLEGHENY RIVER BLVD
VERONA, PA 15147
Pharmacy Comments
Contract Details
Approval Date
8/24/2012
Contract Begin Date
8/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/14/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gerad Theriac, CFO
(412) 641-4466
Contract Pharmacy Representative
Debra Krasnow, Director of Managed Care
(412) 968-1550
Signed By Date
8/10/2012
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