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APOTHECARY & WELLNESS CENTER
DSH070007 LAWRENCE & MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
LAWRENCE & MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070007
Entity Address
365 MONTAUK AVENUE
NEW LONDON, CT 06320-4700
Medicare Provider Number
070007
Participating Start Date
7/1/2019
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
APOTHECARY & WELLNESS CENTER
Pharmacy Address
1450 CHAPEL STREET
NEW HAVEN, CT 06511-4405
Pharmacy Comments
Contract Details
Approval Date
10/4/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/27/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Seth Van Essendelft, CFO
(860) 442-0711 Ext: 2211
Contract Pharmacy Representative
YALE NEW HAVEN HOSPITAL
Terri Sue Bukowski, Manager, Apothecary
(203) 789-4076
Signed By Date
10/4/2016
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