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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 # 05462
1991 SPROUL RD.
BROOMALL, PA 19008
Pharmacy Comments
Contract Details
Approval Date
4/18/2013
Contract Begin Date
7/1/2013
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
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
4/18/2013
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