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VIRGINIA CVS PHARMACY, L.L.C.
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
VIRGINIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01397
1452 CHAIN BRIDGE ROAD
MCLEAN, VA 22101
Pharmacy Comments
Contract Details
Approval Date
4/18/2017
Contract Begin Date
7/1/2017
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
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/18/2017
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