Contract Pharmacy Details

PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390081 Delaware County Memorial Hospital

Covered Entity Details

Entity Name

Delaware County Memorial Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH390081

Entity Address

501 N. Lansdowne Avenue
Drexel Hill, PA 19026-1186

Medicare Provider Number

390081

Participating Start Date

7/1/2012

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 # 03142
119 E. BALTIMORE AVE.
LANSDOWNE, PA 19050

Pharmacy Comments

Contract Details

Approval Date

12/12/2012

Contract Begin Date

1/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2016
Ownership change

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

340B Drug Pricing Program Database