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COORDINATED CARE NETWORK PHARMACY
DSH310096 ST. MICHAEL'S MEDICAL CENTER, INC.
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Covered Entity Details
Entity Name
ST. MICHAEL'S MEDICAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH310096
Entity Address
111 CENTRAL AVENUE
NEWARK, NJ 07102
Medicare Provider Number
310096
Participating Start Date
10/1/2004
Last Recertification Date
8/5/2015
Entity Termination Date
7/1/2016
Pharmacy Details
Pharmacy Name
COORDINATED CARE NETWORK PHARMACY
Pharmacy Address
268 MARTIN LUTHER KING JR. BLVD.
NEWARK, NJ 07102
Pharmacy Comments
Contract Details
Approval Date
12/31/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dennis Pettigrew, CFO/COO
(973) 854-3523
Contract Pharmacy Representative
CCN AMERICA LP
Thomas J. Pollack, Vice President and CFO
(412) 349-6303
Signed By Date
10/3/2012
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