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PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390180 Crozer Chester Medical Center
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Covered Entity Details
Entity Name
Crozer Chester Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390180
Entity Address
One Medical Center Blvd
Upland, PA 19013-3995
Medicare Provider Number
390180
Participating Start Date
4/1/2012
Last Recertification Date
8/11/2015
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00828
5020 PENNELL RD.
ASTON, PA 19014
Pharmacy Comments
Contract Details
Approval Date
12/10/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/9/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Philip J. Ryan, Senior VP & CFO
(610) 338-8228
Contract Pharmacy Representative
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
10/12/2012
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