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CYSTIC FIBROSIS SERVICES, LLC
DSH470011 Brattleboro Memorial Hospital
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Covered Entity Details
Entity Name
Brattleboro Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470011
Entity Address
17 Belmont Avenue
Brattleboro, VT 05301
Medicare Provider Number
470011
Participating Start Date
7/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
1/5/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Rogers, Vice President, Finance
(802) 257-8279
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/5/2018
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