Contract Pharmacy Details

MEDSTAR PHARMACY (STORE #9)
DSH210028 ST. MARYS HOSPITAL

Covered Entity Details

Entity Name

ST. MARYS HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH210028

Entity Address

25500 POINT LOOKOUT RD
LEONARDTOWN, MD 20650

Medicare Provider Number

210028

Participating Start Date

7/1/2016

Last Recertification Date

11/15/2017

Entity Termination Date

8/27/2018

Pharmacy Details

Pharmacy Name

MEDSTAR PHARMACY (STORE #9)

Pharmacy Address

25500 POINT LOOKOUT RD
LEONARDTOWN, MD 20650-2015

Pharmacy Comments

Contract Details

Approval Date

5/2/2016

Contract Begin Date

7/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Richard A. Braam, Chief Financial Officer
(304) 475-6003

Contract Pharmacy Representative

MedStar Health
Bonnie Levin, AVP, Pharmacy Services
(410) 772-6773

Signed By Date

5/2/2016

340B Drug Pricing Program Database