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COMMCARE PHARMACY-FTL, LLC
DSH490063 INOVA FAIRFAX HOSPITAL
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Covered Entity Details
Entity Name
INOVA FAIRFAX HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490063
Entity Address
3300 Gallows Road
Falls Church, VA 22042
Medicare Provider Number
490063
Participating Start Date
10/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
COMMCARE PHARMACY-FTL, LLC
Pharmacy Address
855 SW 78TH AVE STE C100
PLANTATION, FL 33324-3223
Pharmacy Comments
Contract Details
Approval Date
4/14/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/13/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patrick Christiansen, CEO
(703) 776-3050
Contract Pharmacy Representative
Inova Fairfax Medical Campus
Patrice Dupart, Senior Director of Pharmacy Services
(703) 776-2940
Signed By Date
4/14/2016
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