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RHODE ISLAND CVS PHARMACY, L.L.C.
DSH410001 MEMORIAL HOSPITAL OF RHODE ISLAND
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF RHODE ISLAND
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410001
Entity Address
111 BREWSTER ST
PAWTUCKET, RI 02860
Medicare Provider Number
410001
Participating Start Date
7/1/2004
Last Recertification Date
11/15/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
RHODE ISLAND CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04096
309 BROAD ST.
CENTRAL FALLS, RI 02863
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul A. Beaudoin, Senior VP of Finance/CFO Kent
(401) 729-2147
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/15/2015
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