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GIANT EAGLE PHARMACY #0074
DSH390028E UPMC MERCY
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Covered Entity Details
Entity Name
UPMC MERCY
Subdivision Name
UPMC Mercy Southside Outpatient Center - OR
Type
Disproportionate Share Hospital
340B ID
DSH390028E
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 #0074
Pharmacy Address
1165 MCKINNEY LANE
PARKWAY CENTER MALL
PITTSBURGH, PA 15220
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
7/26/2012
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