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VALUE MART PHARMACY
DSH310083 EAST ORANGE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
EAST ORANGE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH310083
Entity Address
300 CENTRAL AVENUE
EAST ORANGE, NJ 07018
Medicare Provider Number
310083
Participating Start Date
10/1/2004
Last Recertification Date
8/29/2015
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
VALUE MART PHARMACY
Pharmacy Address
314 MAIN ST
ORANGE, NJ 07050
Pharmacy Comments
Contract Details
Approval Date
9/14/2012
Contract Begin Date
9/17/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Contacts
Covered Entity Signing Official
Al Aboud, CFO
(973) 414-3405
Contract Pharmacy Representative
Steven Sung, Manager
(973) 676-0866
Signed By Date
9/10/2012
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