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NORTHERN PHARMACY
DSH210008 MERCY MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210008
Entity Address
345 ST. PAUL PLACE
BALTIMORE, MD 21202
Medicare Provider Number
210008
Participating Start Date
10/1/2002
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
NORTHERN PHARMACY
Pharmacy Address
6701 HARFORD RD
BALTIMORE, MD 21234-7721
Pharmacy Comments
Contract Details
Approval Date
4/15/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Morrell Delcher, VP & Chief Pharmacy Officer
(410) 332-9627
Contract Pharmacy Representative
Pepper Mintz, President/COO
(410) 254-2055 Ext: 259
Signed By Date
4/15/2015
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