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GLENDALE PHARMACY
DSH490052 RIVERSIDE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
RIVERSIDE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490052
Entity Address
500 J Clyde Morris Blvd
NEWPORT NEWS, VA 23601
Medicare Provider Number
490052
Participating Start Date
7/1/2008
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
GLENDALE PHARMACY
Pharmacy Address
12444 WARWICK BOULEVARD
NEWPORT NEWS, VA 23606
Pharmacy Comments
Contract Details
Approval Date
9/19/2012
Contract Begin Date
9/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/2/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Wade Broughman, EVP
(757) 534-7035
Contract Pharmacy Representative
Armya Marae, Pharmacist In Charge
(757) 595-3355
Signed By Date
8/27/2012
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