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GOOD HEALTH PHARMACY AT HARBOUR VIEW
DSH490017 Maryview Hospital LLC
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Covered Entity Details
Entity Name
Maryview Hospital LLC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490017
Entity Address
3636 HIGH ST
PORTSMOUTH, VA 23707
Medicare Provider Number
490017
Participating Start Date
4/1/2009
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
GOOD HEALTH PHARMACY AT HARBOUR VIEW
Pharmacy Address
5818-D HARBOUR VIEW BLVD.
SUITE 100
SUFFOLK, VA 23435
Pharmacy Comments
Contract Details
Approval Date
10/4/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/29/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Joseph M. Oddis, CEO
(757) 398-2135
Contract Pharmacy Representative
Aviance Lewis, Pharmacist in Charge
(757) 541-1100
Signed By Date
10/4/2013
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