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MEDSTAR PHARMACY AT GSH
DSH210024A UNION MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
UNION MEMORIAL HOSPITAL
Subdivision Name
UNION MEMORIAL HOSPITAL OUTPATIENT RENAL DIALYSIS UNIT
Type
Disproportionate Share Hospital
340B ID
DSH210024A
Entity Address
201 E UNIVERSITY PARKWAY
BALTIMORE, MD 21218
Medicare Provider Number
210024
Outpatient Facility Provider Number
210024
Participating Start Date
10/1/2010
Last Recertification Date
8/19/2016
Entity Termination Date
7/1/2017
Pharmacy Details
Pharmacy Name
MEDSTAR PHARMACY AT GSH
Pharmacy Address
5601 LOCH RAVEN BLVD
BALTIMORE, MD 21239-2945
Pharmacy Comments
Contract Details
Approval Date
10/7/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Contacts
Covered Entity Signing Official
Deana Stout, VP FINANCE
(410) 554-2228
Contract Pharmacy Representative
MedStar Health
Bonnie Levin, AVP, Pharmacy Services
(410) 772-6773
Signed By Date
10/7/2016
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