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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
James Burke, VP Finance
(401) 737-7010 Ext: 31154
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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