Contract Pharmacy Details

PENNSYLVANIA CVS PHARMACY, L.L.C.
DSH390080 JEANES HOSPITAL

Covered Entity Details

Entity Name

JEANES HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH390080

Entity Address

7600 CENTRAL AVENUE
PHILADELPHIA, PA 19111

Medicare Provider Number

390080

Participating Start Date

10/1/2017

Last Recertification Date

8/19/2019

Entity Termination Date

4/1/2020

Pharmacy Details

Pharmacy Name

PENNSYLVANIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 02074
4133 G ST.
PHILADELPHIA, PA 19124

Pharmacy Comments

Contract Details

Approval Date

10/16/2017

Contract Begin Date

1/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2020
Ownership change

Contacts

Covered Entity Signing Official

Ray Lefton, Chief Financial Officer, Treasurer
(215) 728-3306

Contract Pharmacy Representative

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

Signed By Date

10/16/2017

340B Drug Pricing Program Database