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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390156 MERCY CATHOLIC MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY CATHOLIC MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390156
Entity Address
1500 LANSDOWNE AVE
ATTN: Pharmacy Director
DARBY, PA 19023
Medicare Provider Number
390156
Participating Start Date
7/1/2003
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00675
159 N. MACDADE BLVD.
GLENOLDEN, PA 19036
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Wajda, CFO
(215) 335-6281
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/17/2017
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