Contract Pharmacy Details

MARYLAND CVS PHARMACY, L.L.C.
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

MARYLAND CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 01515
26020 POINT LOOKOUT RD.
LEONARDTOWN, MD 20650

Pharmacy Comments

Contract Details

Approval Date

1/17/2017

Contract Begin Date

4/1/2017

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

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/17/2017

340B Drug Pricing Program Database