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RHODE ISLAND CVS PHARMACY, L.L.C.
DSH410010 WOMEN & INFANTS HOSPITAL OF RHODE ISLAND
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Covered Entity Details
Entity Name
WOMEN & INFANTS HOSPITAL OF RHODE ISLAND
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410010
Entity Address
101 DUDLEY ST.
PROVIDENCE, RI 02905
Medicare Provider Number
410010
Participating Start Date
10/1/2004
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
RHODE ISLAND CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00212
681 RESERVOIR AVENUE
CRANSTON, RI 02910
Pharmacy Comments
Contract Details
Approval Date
10/16/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/3/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark R. Marcantano, President, COO
(401) 274-1122 Ext: 41104
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/16/2015
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