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BRIOVARX OF MAINE INC
DSH210012 SINAI HOSPITAL OF BALTIMORE
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Covered Entity Details
Entity Name
SINAI HOSPITAL OF BALTIMORE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210012
Entity Address
2401 WEST BELVEDERE AVENUE
BALTIMORE, MD 21215
Medicare Provider Number
210012
Participating Start Date
7/1/2003
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
NEIL MELTZER, PRESIDENT/CEO
(410) 601-5134
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
1/17/2017
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