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BAYSIDE PHARMACY & PHYSICIAN
DSH390063 UPMC HAMOT
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Covered Entity Details
Entity Name
UPMC HAMOT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390063
Entity Address
201 STATE STREET
ERIE, PA 16550
Medicare Provider Number
390063
Participating Start Date
4/1/2015
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
BAYSIDE PHARMACY & PHYSICIAN
Pharmacy Address
SUPPLY COMPANY
300 STATE STREET
SUITE 102
ERIE, PA 16507
Pharmacy Comments
Contract Details
Approval Date
4/2/2015
Contract Begin Date
4/3/2015
Carve-In Effective Date
Contract Comments
4/03/2015 - immediate Contract Begin date authorized
Contract Termination Date
Termination Reason
12/14/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Stephen Mark Danch, CFO
(814) 877-6162
Contract Pharmacy Representative
Gregg Moffett, Manager of Pharmacy Operations
(814) 877-6764
Signed By Date
4/2/2015
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