Contract Pharmacy Details

GIANT EAGLE PHARMACY #1619
DSH390028B UPMC MERCY

Covered Entity Details

Entity Name

UPMC MERCY

Subdivision Name

UPMC Mercy Southside Outpatient Center - GI Lab

Type

Disproportionate Share Hospital

340B ID

DSH390028B

Entity Address

2000 Mary Street
Pittsburgh, PA 15203

Medicare Provider Number

390028

Outpatient Facility Provider Number

390028

Participating Start Date

7/1/2012

Last Recertification Date

12/6/2017

Entity Termination Date

10/1/2018

Pharmacy Details

Pharmacy Name

GIANT EAGLE PHARMACY #1619

Pharmacy Address

EDGEWOOD TOWNE CENTER
1705 SOUTH BRADDOCK AVE
PITTSBURGH, PA 15218

Pharmacy Comments

Contract Details

Approval Date

8/15/2012

Contract Begin Date

8/15/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/24/2017
Agreement registered in error

Contacts

Covered Entity Signing Official

Nicholas Barcellona, CFO
(412) 232-8627

Contract Pharmacy Representative

Debra Krasnow, Director of Managed Care
(412) 968-1550

Signed By Date

7/24/2012

340B Drug Pricing Program Database