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COSTCO WHOLESALE CORPORATION
DSH220077 BAYSTATE MEDICAL CENTER
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Covered Entity Details
Entity Name
BAYSTATE MEDICAL CENTER
Subdivision Name
BAYSTATE NORTH CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH220077
Entity Address
759 CHESTNUT STREET
SPRINGFIELD, MA 01199
Medicare Provider Number
220077
Participating Start Date
7/1/2003
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
COSTCO WHOLESALE CORPORATION
Pharmacy Address
DBA COSTCO PHARMACY #302
119 DAGGETT DRIVE
WEST SPRINGFIELD, MA 01089
Pharmacy Comments
Contract Details
Approval Date
5/23/2012
Contract Begin Date
5/23/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/5/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dennis Chalke, Sr. VP Finance & Community Hospitals/CFO & Treasurer
(413) 794-3290
Contract Pharmacy Representative
Christopher Pierce, AVP Pharmacy Benefits
(425) 427-7986
Signed By Date
5/4/2012
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