Covered Entity Details

DSH330046A MOUNT SINAI WEST (Active) - information as of 4/25/2025 6:32:26 PM

Main Details

Name

MOUNT SINAI WEST

Subdivision Name

ROOSEVELT HOSPITAL

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330046A

Medicare Provider Number

330046

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/1/2005

Participating Start Date

7/1/2005

Participating Approval Date

6/2/2005

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Mount Sinai
Michael Pastier, Senior VP/CFO - The Mount Sinai Hospital
(212) 731-3149

Primary Contact

Mount Sinai Health System
Samuel Wilhelm-Ross, 340B Program Director
(646) 605-2006

Addresses

Street Address

1000 10TH AVENUE
NEW YORK, NY 10019

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
NEW ADD 7/05	10/09/2009

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
NY	01650173,00354967,03001810,02239247,02640706	1104982917,1508001405,1417192311

Shipping Addresses

Shipping Address 1

SLRHC West Village Pharmacy
230 West 17th St
8th Fl
New York, NY 10011

Shipping Address 2

ST LUKE'S ROOSEVELT HOSPITAL CENTER
445 W 58TH STREET
NEW YORK, NY 10019

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	58TH STREET PHARMACY, INC.	DBA TOWN DRUG AND SURGICAL	428 WEST 59TH STREET	NEW YORK	NY	10019	04/02/2007	04/02/2007	06/27/2019	06/28/2019
Contract Detail	ACARIAHEALTH PHARMACY #12, INC.	5 SKYLINE DR STE 240		HAWTHORNE	NY	10532-2166	10/06/2015	01/01/2016	10/03/2019	10/03/2019
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/16/2015	01/01/2016	07/08/2019	07/09/2019
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/13/2016	01/01/2017	01/03/2019	01/03/2019
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	10/13/2016	01/01/2017	01/03/2019	01/03/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/16/2015	01/01/2016	07/08/2019	07/09/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/13/2016	01/01/2017	01/03/2019	01/03/2019
Contract Detail	CITY DRUGS NY CORP.	D/B/A CITY DRUGS	1551 YORK AVE	NEW YORK	NY	10028-6022	10/13/2016	01/01/2017	01/09/2019	01/09/2019
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/14/2017	10/01/2017	10/03/2019	10/03/2019
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	255 PHILLIPI ROAD	COLUMBUS	OH	43228	07/14/2017	10/01/2017	06/18/2018	07/23/2018
Contract Detail	ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI	ICAHN SCHOOL OF MEDICINE PHARMACY	1468 MADISON AVE ANNENBERG-MC LEVEL	NEW YORK	NY	10029	04/15/2016	07/01/2016	06/27/2019	06/28/2019
Contract Detail	KINGS PARK SLOPE INC	D/B/A KINGS SUPER PHARMACY	357 FLATBUSH AVE	BROOKLYN	NY	11238	04/15/2016	07/01/2016	06/27/2019	06/28/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330046A	Child	DSH	MOUNT SINAI WEST	ROOSEVELT HOSPITAL	1000 10TH AVENUE	NEW YORK	NY	Active
DSH330046B	Child	DSH	MOUNT SINAI WEST	ST LUKE'S HOSPITAL	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046C	Child	DSH	ST LUKE'S ROOSEVELT HOSPITAL CENTER	TRANSPLANT PROGRAM	2074 Frederick Douglas Boulevard	NEW YORK	NY	Terminated
DSH330046D	Child	DSH	MOUNT SINAI WEST	Ambulatory Psychiatric Center - PTSD	411 West 114th Street	New York City	NY	Active
DSH330046E	Child	DSH	MOUNT SINAI WEST	Center for Comprehensive Care West 17th Street Division	230 west 17th street	New York City	NY	Terminated
DSH330046F	Child	DSH	MOUNT SINAI WEST	Ambulatory Psychatric Center/Mental health Day Treatment	411 west 114th street	New York City	NY	Active
DSH330046G	Child	DSH	MOUNT SINAI WEST	Ambulatory Psychatric Center/Mental health Clinic	411 west 114th street	New York City	NY	Active
DSH330046H	Child	DSH	MOUNT SINAI WEST	Opioid Treatment Program (MMTP)	1000 TENTH AVENUE	NEW YORK	NY	Active
DSH330046J	Child	DSH	ST. LUKES ROOSEVELT HOSPITAL CENTER	A. PHILIP RANDOLPH CAMPUS HIGH SCHO	443 WEST 135TH STREET	NEW YORK	NY	Terminated
DSH330046K	Child	DSH	ST. LUKES ROOSEVELT HOSPITAL CENTER	MARTIN LUTHER KING JR. HIGH SCHOOL	122 AMSTERDAM AVENUE	NEW YORK	NY	Terminated
DSH330046L	Child	DSH	ST. LUKES ROOSEVELT HOSPITAL CENTER	LOUIS BRANDEIS HIGH SCHOOL	145 WEST 84TH STREET	NEW YORK	NY	Terminated
DSH330046M	Child	DSH	MOUNT SINAI WEST	CARDIOLOGY CLINIC	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046N	Child	DSH	MOUNT SINAI WEST	ST. LUKE'S INFECTIOUS DISEASE CLINIC	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046P	Child	DSH	MOUNT SINAI WEST	MOUNT SINAI ST. LUKE'S SURGERY CLINIC	1111 AMSTERDAM AVENUE	NEW YORK	NY	Active
DSH330046Q	Child	DSH	MOUNT SINAI WEST	ST. LUKE'S GENERAL CLINIC	158 W 124th St	New York	NY	Active
DSH330046R	Child	DSH	MOUNT SINAI WEST	MOUNT SINAI WEST INFUSION	425 W 59th Street	New York	NY	Active
DSH330046S	Child	DSH	MOUNT SINAI WEST	MOUNT SINAI Saint Luke's Outpatient Clinic	1111 Amsterdam Ave.	New York	NY	Active
DSH330046T	Child	DSH	MOUNT SINAI WEST	Mount Sinai St. Luke's - Emergency Department	1111 Amsterdam Ave	New York	NY	Active
DSH330046U	Child	DSH	MOUNT SINAI WEST	Mount Sinai Morningside - Institute for Advanced Medicine	158 W 124th St	New York	NY	Active
DSH330046V	Child	DSH	MOUNT SINAI WEST	Mount Sinai Morningside - Oncology	440 W 114th St	New York	NY	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 11:31:26 AM	8/12/2024 9:01:33 AM	8/12/2024 9:01 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 9:30:08 AM	8/14/2023 11:31:26 AM	8/14/2023 11:31 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 12:51:00 PM	8/26/2022 9:30:08 AM	8/26/2022 9:30 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 9:41:29 AM	8/16/2021 12:51:00 PM	8/16/2021 12:51 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00354967 (NY)		9/4/2020 9:41 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 9:41 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 9:41 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/4/2020 9:41 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 12:01:15 PM	9/4/2020 9:41:29 AM	9/4/2020 9:41 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 4:10:25 PM	8/20/2019 12:01:15 PM	8/20/2019 12:01 PM
Contacts	Primary Contact	Update	Profile Change Request	Wilhelm-Ross, Samuel 340B Program Director Mount Sinai Health System 7182674352	Wilhelm-Ross, Samuel 340B Program Director Mount Sinai Health System 6466052006	5/14/2019 9:25 AM
Contacts	Primary Contact	Update	Change Request	Manning, Philip Senior Director of Pharmacy mount sinai health system 7182674295	Wilhelm-Ross, Samuel 340B Program Director Mount Sinai Health System 7182674352	12/12/2018 11:31 AM
Contacts	Authorizing Official	Update	Change Request	Bruno, Michael Sr. Vice President Beth Israel Medicial Center 2125237140	Pastier, Michael Senior VP/CFO - The Mount Sinai Hospital Mount Sinai 2127313149	10/26/2018 1:38 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 2:04:10 PM	8/23/2018 4:10:25 PM	8/23/2018 4:10 PM
Details	Entity Name	Update	Change Request	ST LUKE'S ROOSEVELT HOSPITAL CENTER	MOUNT SINAI WEST	7/30/2018 2:04 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/7/2017 2:04:10 PM	11/7/2017 2:04 PM
Contacts	Authorizing Official	Update		Bruno, Michael Sr. Vice President 2125237140	Bruno, Michael Sr. Vice President Beth Israel Medicial Center 2125237140	10/13/2017 8:57 AM
Contacts	Primary Contact	Update		Manning, Philip Senior Director of Pharmacy 7182674295	Manning, Philip Senior Director of Pharmacy mount sinai health system 7182674295	10/6/2017 11:08 AM
Contacts	Authorizing Official	Insert			Bruno, Michael Sr. Vice President 2125237140	8/3/2017 10:15 AM
Contacts	Primary Contact	Update		Kolak, Pascal ACTING DIRECTOR OF PHARMACY 2125236550	Manning, Philip Senior Director of Pharmacy 7182674295	8/3/2017 10:15 AM
Addresses	Main Address	Insert			1000 10TH AVENUE NEW YORK, NY 10019	8/3/2017 10:15 AM
Addresses	Shipping Address	Insert			ST LUKE'S ROOSEVELT HOSPITAL CENTER 445 W 58TH STREET NEW YORK, NY 10019	8/3/2017 10:15 AM
Addresses	Shipping Address	Insert			SLRHC West Village Pharmacy 230 West 17th St 8th Fl New York, NY 10011	8/3/2017 10:15 AM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 12:03 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/31/2015 12:30 PM
Details	Last Recertification Date	Update		9/9/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 12:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/2/2015 8:14 AM
Medicaid Billing	Medicaid: Number	Insert			02640706	3/2/2015 8:14 AM
Medicaid Billing	Medicaid: State	Insert			NY	3/2/2015 8:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Number	Insert			01650173	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: State	Insert			NY	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Number	Insert			00354967	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: State	Insert			NY	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Number	Insert			03001810	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: State	Insert			NY	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: Number	Insert			02239247	9/9/2014 11:34 AM
Medicaid Billing	Medicaid: State	Insert			NY	9/9/2014 11:34 AM
Medicaid Billing	NPI: Number	Insert			1104982917	9/9/2014 11:34 AM
Medicaid Billing	NPI: Number	Insert			1508001405	9/9/2014 11:34 AM
Medicaid Billing	NPI: Number	Insert			1417192311	9/9/2014 11:34 AM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	9/9/2014 12:00:00 AM	9/9/2014 11:34 AM
Contacts	Primary Contact	Update		ROMEO, BARBARA DIRECTOR OF PHARMACY 2125236550	Kolak, Pascal ACTING DIRECTOR OF PHARMACY 2125236550	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 11:22 AM
Contacts	Primary Contact	Insert			ROMEO, BARBARA DIRECTOR OF PHARMACY 2125236550	5/29/2012 2:29 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 2:29 PM
Details	Last Recertification Date	Insert				10/9/2009 4:07 PM
Details	Grant Number	Insert				10/9/2009 4:07 PM
Details	340B ID	Insert			DSH330046A	10/9/2009 4:07 PM
Details	Is Authorizing Official EHB Data	Insert				10/9/2009 4:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/9/2009 4:07 PM
Details	Medicare Provider Number	Insert			330046	10/9/2009 4:07 PM
Details	Entity Name	Insert			ST LUKE'S ROOSEVELT HOSPITAL CENTER	10/9/2009 4:07 PM
Details	Program Code	Insert			DSH	10/9/2009 4:07 PM
Details	Entity Subname	Insert			ROOSEVELT HOSPITAL	10/9/2009 4:07 PM
Dates	Participating Approval Date	Insert			6/2/2005 12:00:00 AM	10/9/2009 4:07 PM
Details	State	Insert			Active	10/9/2009 4:07 PM
Dates	Registration Date	Insert			7/1/2005 12:00:00 AM	10/9/2009 4:07 PM
Dates	Signed By Date	Insert			4/26/2005 12:00:00 AM	10/9/2009 4:07 PM
Dates	Start Date	Insert			7/1/2005 12:00:00 AM	10/9/2009 4:07 PM
Terminations	Termination Comments	Insert				10/9/2009 4:07 PM
Terminations	Termination Date	Insert				10/9/2009 4:07 PM
Terminations	Termination Effective Date	Insert				10/9/2009 4:07 PM
Terminations	Termination Reason	Insert				10/9/2009 4:07 PM
Details	Comments Public	Insert			NEW ADD 7/05	10/9/2009 4:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	7/1/2005 12:00 AM
Medicaid Billing	Medicaid: Number	Insert			00354967	7/1/2005 12:00 AM
Medicaid Billing	Medicaid: State	Insert			NY	7/1/2005 12:00 AM