Covered Entity Details

DSH330350 UNIVERSITY HOSPITAL OF BROOKLYN (Active) - information as of 4/27/2025 1:48:44 AM

Main Details

Name

UNIVERSITY HOSPITAL OF BROOKLYN

Subdivision Name

SUNY DOWNSTATE MEDICAL CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330350

Medicare Provider Number

330350

Additional Details

Current Program Status

Active

Registration Date

9/14/2007

Participating Start Date

12/1/1992

Participating Approval Date

9/14/2007

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

SUNY Downstate
Sean Patrick Smith, Senior Associate Vice President & Deputy Chief Financial Officer
(718) 826-4943

Primary Contact

UNIVERSITY HOSPITAL OF BROOKLYN
Hossameldin Ghanem, Pharmacy 340B Manager
(718) 270-7648

Addresses

Street Address

445 LENOX ROAD
Attn: Pharmacy Box 36
BROOKLYN, NY 11203

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
9/14/07 ADMIN CORRECTION (REVERSED ENT NAME AND SUB-DIV NAME)	10/30/2007

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	02998676,02998694	1639179328

Shipping Addresses

Shipping Address 1

University Hospital of Brooklyn
445 Lenox Road
Attn: Pharmacy Box 36
Brooklyn, NY 11203

Shipping Address 2

SUNY Downstate Health Sciences University- University Hospital of Brooklyn
450 Clarkson Avenue
Brooklyn, NY 11203

Shipping Address 3

SUNY Outpatient Pharmacy
470A Clarkson Ave
Brooklyn, NY 11203

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	1746 PHARMACY CORP	DBA: CLARKSON PHARMACY	524 CLARKSON AVE	BROOKLYN	NY	11203-2015	01/15/2015	04/01/2015	03/04/2019	03/04/2019
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/13/2018	07/01/2018		04/13/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/13/2018	07/01/2018		04/13/2018
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/13/2018	07/01/2018	03/04/2019	03/04/2019
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/13/2018	07/01/2018		04/13/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/13/2018	07/01/2018	03/04/2019	03/04/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/13/2018	07/01/2018	03/04/2019	03/04/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/13/2018	07/01/2018		04/13/2018
Contract Detail	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	04/06/2015	07/01/2015	09/20/2017	09/21/2017
Contract Detail	AVELLA OF ORLANDO	100 TECHNOLOGY PARK STE 155		LAKE MARY	FL	32746-6205	04/06/2015	07/01/2015	09/20/2017	09/21/2017
Contract Detail	CRYSTAL DRUGS INC	MICHAEL'S PHARMACY	163 LINDEN BLVD	BROOKLYN	NY	11226	04/15/2019	07/01/2019	11/01/2024	02/27/2025
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/14/2020	10/01/2020		10/01/2020
Contract Detail	DELIVER MY MEDS CORP.	380 OSER AVE		HAUPPAUGE	NY	11788-3608	04/15/2019	07/01/2019	10/01/2021	10/18/2021
Contract Detail	DUANE READE	724 FLATBUSH AVENUE		BROOKLYN	NY	11226	07/14/2020	10/01/2020		10/01/2020
Contract Detail	DUANE READE	16 COURT STREET		BROOKLYN	NY	11241-0102	10/14/2021	01/01/2022		01/01/2022
Contract Detail	DUANE READE	2265 RALPH AVENUE		BROOKLYN	NY	11234	10/14/2021	01/01/2022		01/01/2022
Contract Detail	DUANE READE	756 MYRTLE AVE		BROOKLYN	NY	11206	10/14/2021	01/01/2022		01/01/2022
Contract Detail	DUANE READE	1517 CORTELYOU ROAD		BROOKLYN	NY	11226	10/14/2021	01/01/2022		01/01/2022
Contract Detail	DUANE READE	1915 THIRD AVE		NEW YORK	NY	10029	01/14/2022	04/01/2022		04/01/2022
Contract Detail	DUANE READE	559 FULTON STREET		BROOKLYN	NY	11201-5309	01/14/2022	04/01/2022	02/17/2022	05/26/2023
Contract Detail	DUANE READE	296 FLATBUSH AVE		BROOKLYN	NY	11217-2812	01/14/2022	04/01/2022		04/01/2022
Contract Detail	DUANE READE	54-11 MYRTLE AVENUE		RIDGEWOOD	NY	11385	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	13602 ROOSEVELT AVENUE		FLUSHING	NY	11354	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	386 FULTON ST		BROOKLYN	NY	11201	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	300 WEST 135TH ST.		NEW YORK	NY	10030	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	5008 5TH AVE		BROOKLYN	NY	11220	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	250 BEDFORD AVENUE		BROOKLYN	NY	11249	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	155 EAST 34TH STREET		NEW YORK	NY	10016-4766	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	116-02 BEACH CHANNEL DRIVE		FAR ROCKAWAY	NY	11694	07/17/2023	10/01/2023		10/01/2023
Contract Detail	DUANE READE	DBA DUANE READE	575 LEXINGTON AVE	NEW YORK	NY	10022-6102	07/17/2023	10/01/2023	04/10/2024	04/23/2024
Contract Detail	DUANE READE	485 LEXINGTON AVENUE		NEW YORK	NY	10017	04/15/2024	07/01/2024		07/01/2024
Contract Detail	EXPRESS HEALTH MART PHARMACY CORP.	1173 NOSTRAND AVE		BROOKLYN	NY	11225	04/15/2015	07/01/2015	03/04/2019	03/04/2019
Contract Detail	EXPRESS HEALTH MART PHARMACY CORP.	1173 NOSTRAND AVE		BROOKLYN	NY	11225	04/15/2019	07/01/2019	10/01/2021	10/18/2021
Contract Detail	KALA PHARMACY INC	9311 CHURCH AVE		BROOKLYN	NY	11212-1645	01/03/2019	04/01/2019	11/01/2024	02/27/2025
Contract Detail	KINGS DRUG & SURGICAL CORP	492 CLARKSON AVE		BROOKLYN	NY	11203-2013	01/06/2015	04/01/2015		01/06/2015
Contract Detail	KINGS PARK SLOPE INC	D/B/A KINGS SUPER PHARMACY	357 FLATBUSH AVE	BROOKLYN	NY	11238	01/06/2015	04/01/2015	02/01/2024	05/14/2024
Contract Detail	MEDLY PHARMACY INC.	DBA MEDLY PHARMACY	31 DEBEVOISE ST	BROOKLYN	NY	11206-4196	01/03/2019	04/01/2019	10/01/2024	02/27/2025
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	04/15/2015	07/01/2015	03/13/2018	03/14/2018
Contract Detail	OPTUM INFUSION SERVICES 101, INC.	931 CONKLIN ST STE D		FARMINGDALE	NY	11735-2429	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/07/2025	04/01/2025		04/01/2025
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/07/2025	04/01/2025		04/01/2025
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/14/2020	10/01/2020	08/31/2022	07/30/2024
Contract Detail	RUTLAND PHARMACY LLC	964 RUTLAND RD		BROOKLYN	NY	11212-1544	04/15/2019	07/01/2019	05/02/2022	05/11/2022
Contract Detail	SHANTI PHARMACYCORP	D/B/A SILVER ROD DRUGS	5105 CHURCH AVE	BROOKLYN	NY	11203	01/03/2019	04/01/2019		04/01/2019
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/15/2015	07/01/2015		04/15/2015
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	04/12/2018	07/01/2018	01/01/2024	05/14/2024
Contract Detail	STATE UNIVERSITY OF NEW YORK	OUTPATIENT PHARMACY	750 E ADAMS ST LOBBY	SYRACUSE	NY	13210	04/21/2021	04/22/2021	10/14/2022	10/14/2022
Contract Detail	WALGREEN EASTERN CO., INC	DBA: WALGREENS	1847 ROCKAWAY PKWY.	BROOKLYN	NY	11236-5307	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #10941	3000 CHURCH AVE.	BROOKLYN	NY	11226-4210	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	5001 CHURCH AVE.	BROOKLYN	NY	11203-1320	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 18961	4123 AVENUE D	BROOKLYN	NY	11203-5705	07/14/2020	10/01/2020	12/09/2021	03/14/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #15352	1281 FULTON ST.	BROOKLYN	NY	11216	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #19994	1040 SAINT JOHNS PL.	BROOKLYN	NY	11213-2533	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #17670	1559 FLATBUSH AVE	BROOKLYN	NY	11210	07/14/2020	10/01/2020	11/08/2023	11/14/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	1134 E. NEW YORK AVE.	BROOKLYN	NY	11212	07/14/2020	10/01/2020	11/11/2020	11/17/2020
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	4915 FLATLANDS AVE.	BROOKLYN	NY	11234	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 18228	1111 PENNSYLVANIA AVE	BROOKLYN	NY	11207-9000	07/14/2020	10/01/2020	11/07/2024	11/17/2024
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #17802	506-528 UTICA AVENUE	BROOKLYN	NY	11203	07/14/2020	10/01/2020	11/10/2022	04/24/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11141	1366 BROADWAY	BROOKLYN	NY	11221	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #10678	379 MYRTLE AVE.	BROOKLYN	NY	11205-2407	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 17968	7821 3RD AVE	BROOKLYN	NY	11209	10/14/2021	01/01/2022	10/14/2021	08/03/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18321	2532-54 86TH ST	BROOKLYN	NY	11214	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02650	5716 AVENUE U	BROOKLYN	NY	11234	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04445	119-02 ROCKAWAY BLVD.	SOUTH OZONE PARK	NY	11420	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17979	78-14 LINDEN BLVD	HOWARD BEACH	NY	11414	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS SPECIALTY PHARMACY #16511	306 CLARKSON AVE.	BROOKLYN	NY	11226	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	2325 FLATBUSH AVE.	BROOKLYN	NY	11234-4529	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #19158	1419 NEWKIRK AVE	BROOKLYN	NY	11226-6521	10/14/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 17814	6101 18TH AVE	BROOKLYN	NY	11204	01/14/2022	04/01/2022	10/12/2022	10/14/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18204	355 KNICKERBOCKER AVE	BROOKLYN	NY	11237-3740	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 01918	755 BROADWAY	BROOKLYN	NY	11206-5320	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS	1242 LIBERTY AVE.	BROOKLYN	NY	11208	01/14/2022	04/01/2022	02/22/2023	07/05/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11806	114 BEVERLEY RD.	BROOKLYN	NY	11218-3914	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #19959	5801 QUEENS BLVD	WOODSIDE	NY	11377	01/14/2022	04/01/2022	07/29/2022	08/12/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 01487	104-25-31 QUEENS BLV	FOREST HILLS	NY	11375	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #13706	110 MOUNTAIN BLVD	WARREN	NJ	07059	01/14/2022	04/01/2022	10/12/2022	10/14/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #16512	3462 JEROME AVE.	BRONX	NY	10467	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 01214	1328 2ND AVE	NEW YORK	NY	10021	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17680	16040 CROSS BAY BLVD	HOWARD BEACH	NY	11414	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 18305	120 COURT ST	BROOKLYN	NY	11201	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11427	1409 AVENUE J	BROOKLYN	NY	11230	10/14/2022	01/01/2023	11/08/2022	01/05/2024
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #16078	205 8TH AVENUE	NEW YORK	NY	10011	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17926	4232 BAYCHESTER AVE	BRONX	NY	10466	10/14/2022	01/01/2023	02/20/2025	02/27/2025
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #15097	589 PROSPECT AVE	BROOKLYN	NY	11215	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04564	159-34 JAMAICA AVE	JAMAICA	NY	11432-6001	10/14/2022	01/01/2023	11/07/2023	11/14/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 17613	9001 SUTPHIN BLVD	JAMAICA	NY	11435	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04363	210 UNION AVENUE	BROOKLYN	NY	11211	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 05051	21914 MERRICK BLVD	LAURELTON	NY	11413	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS	290 WEST MERRICK ROAD	VALLEY STREAM	NY	11580	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03457	393 FRONT ST	HEMPSTEAD	NY	11550	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02055	109-62 FRANCIS LEWIS BLVD	QUEENS VILLAGE	NY	11429	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	132-50 METROPOLITAN AVE.	RICHMOND HILL	NY	11418	10/14/2022	01/01/2023	01/21/2025	02/27/2025
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17151	10640 ROCKAWAY BEACH BLVD	ROCKAWAY PARK	NY	11694	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS # 19694	11088 QUEENS BLVD.	FOREST HILLS	NY	11375	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #19195	650 E TREMONT AVE	BRONX	NY	10457	10/14/2022	01/01/2023	11/09/2022	01/08/2024
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18219	1720 KINGS HWY	BROOKLYN	NY	11229	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	3082 AVENUE U	BROOKLYN	NY	11229	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04565	12704 GUY R BREWER BLVD	JAMAICA	NY	11434	10/14/2022	01/01/2023		01/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07321	1227 FOREST AVE	STATEN ISLAND	NY	10310-2416	07/17/2023	10/01/2023		10/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17269	750 MANHATTAN AVE	BROOKLYN	NY	11222-2910	07/17/2023	10/01/2023		10/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	9408 3RD AVE.	BROOKLYN	NY	11209-6804	07/17/2023	10/01/2023		10/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	2201 HEMPSTEAD TURNPIKE SUITE 1-413	EAST MEADOW	NY	11554	04/15/2024	07/01/2024		07/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/14/2020	10/01/2020		10/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330350A	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	SUNY DOWNSTATE AT BAY RIDGE	699 92ND STREET	BROOKLYN, NEW YORK	NY	Terminated
DSH330350B	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	Ambulatory Surgery Center at Bay Ridge	699 92nd Street	Brooklyn	NY	Terminated
DSH330350C	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	Endoscopy Clinic at Bay Ridge	699 92nd Street	Brooklyn	NY	Terminated
DSH330350D	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	Urgent Care Center at Bay Ridge	699 92nd Street	Brooklyn	NY	Terminated
DSH330350E	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	Center for Health Services - Midwood - Ophthalmology	2171 Nostrand Ave	Brooklyn	NY	Terminated
DSH330350F	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	UHB Family Health Services - Family Health	840 Lefferts Ave	brooklyn	NY	Terminated
DSH330350G	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	PS 142 Stranahan - School Based Hospital Extension Clinic	610 Henry Street	Brooklyn	NY	Terminated
DSH330350H	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	PS 13 - School Based Hospital Extension Clinic	557 Pennsylvania Ave	Brookyn	NY	Terminated
DSH330350J	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	MS 293 Global Studies - School Based Hospital Extension Clinic	284 Baltic Street	Brooklyn	NY	Terminated
DSH330350K	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	PS 38 - School Based Hospital Extension Clinic	450 Pacific Street	Brooklyn	NY	Terminated
DSH330350L	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	MS 51 -Alexander - School Based Hospital Extension Clinic	350 5th Ave	brooklyn	NY	Terminated
DSH330350M	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	SUNY-Parkside Dialysis Center - Dialysis	710 Parkside Avenue	Brooklyn	NY	Active
DSH330350N	Child	DSH	UNIVERSITY HOSPITAL OF BROOKLYN	SUNY Downstate Family Medicine clinic - Family Health	253 Empire Blvd	Brooklyn	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/22/2023 4:40:43 PM	8/23/2024 11:09:40 AM	8/23/2024 11:09 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 9:02:59 AM	8/22/2023 4:40:43 PM	8/22/2023 4:40 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 9:41:53 AM	9/13/2022 9:02:59 AM	9/13/2022 9:02 AM
Contacts	Authorizing Official	Update	AO Change Request	Miller, Richard Bayard Chief Financial OIfficer University Hospital of Brooklyn 7182704901	Smith, Sean Patrick Senior Associate Vice President & Deputy Chief Financial Officer SUNY Downstate 7188264943	9/22/2021 12:04 PM
Addresses	Shipping Address	Insert	Recertification		SUNY Outpatient Pharmacy 470A Clarkson Ave Brooklyn, NY 11203	9/10/2021 9:41 AM
Details	Last Recertification Date	Update	Recertification	9/7/2020 9:59:14 AM	9/10/2021 9:41:53 AM	9/10/2021 9:41 AM
Addresses	Shipping Address	Insert	Recertification		SUNY Downstate Health Sciences University- University Hospital of Brooklyn 450 Clarkson Avenue Brooklyn, NY 11203	9/7/2020 9:59 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/7/2020 9:59 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		02998676	9/7/2020 9:59 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/7/2020 9:59 AM
Medicaid Billing	NPI: State	Update	Recertification		NY	9/7/2020 9:59 AM
Details	Last Recertification Date	Update	Recertification	9/10/2019 8:27:14 AM	9/7/2020 9:59:14 AM	9/7/2020 9:59 AM
Contacts	Primary Contact	Update	Change Request	Richards, Ivor Ian Associate Director of Pharmacy University Hospital of Brooklyn 7182216978	Ghanem, Hossameldin Pharmacy 340B Manager UNIVERSITY HOSPITAL OF BROOKLYN 7182707648	4/3/2020 10:14 AM
Details	Last Recertification Date	Update	Recertification	8/28/2018 3:09:16 PM	9/10/2019 8:27:14 AM	9/10/2019 8:27 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	00243590	02998694	4/10/2019 10:47 AM
Addresses	Shipping Address	Insert	Change Request		University Hospital of Brooklyn 445 Lenox Road Attn: Pharmacy Box 36 Brooklyn, NY 11203	3/4/2019 10:48 AM
Addresses	Shipping Address	Delete	Change Request	SUNY Downstate Medical Center at LICH 445 Lenox Road Attn: Pharmacy Box 36 Brooklyn, NY 11203		3/4/2019 10:48 AM
Contacts	Primary Contact	Update	Change Request	Galeota, Nicholas Director of Pharmacy University Hospital of Brooklyn 7183562168	Richards, Ivor Ian Associate Director of Pharmacy University Hospital of Brooklyn 7182216978	2/28/2019 3:39 PM
Contacts	Authorizing Official	Update	AO Change Request	Walsh, William CEO SUNY University Hospital of Brooklyn 7182704293	Miller, Richard Bayard Chief Financial OIfficer University Hospital of Brooklyn 7182704901	9/3/2018 7:29 AM
Contacts	Primary Contact	Update	Recertification	GALEOTA, NICHOLAS DIRECTOR OF PHARMACY University Hospital opf Brooklyn 7182703115	Galeota, Nicholas Director of Pharmacy University Hospital of Brooklyn 7183562168	8/28/2018 3:09 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 9:23:32 AM	8/28/2018 3:09:16 PM	8/28/2018 3:09 PM
Details	Last Recertification Date	Update	Recertification	10/25/2017 3:05:12 PM	11/7/2017 9:23:32 AM	11/7/2017 9:23 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	10/25/2017 3:05:12 PM	10/25/2017 3:05 PM
Contacts	Authorizing Official	Update		Walsh, William CEO 7182704293	Walsh, William CEO SUNY University Hospital of Brooklyn 7182704293	9/21/2017 1:16 PM
Contacts	Primary Contact	Update		GALEOTA, NICHOLAS DIRECTOR OF PHARMACY 7182703115	GALEOTA, NICHOLAS DIRECTOR OF PHARMACY University Hospital opf Brooklyn 7182703115	9/20/2017 12:53 PM
Contacts	Authorizing Official	Update		Jones, Anthony K. Interim CEO 7182704293	Walsh, William CEO 7182704293	6/15/2017 11:56 AM
Addresses	Main Address	Insert			445 LENOX ROAD Attn: Pharmacy Box 36 BROOKLYN, NY 11203	8/22/2016 1:20 PM
Contacts	Primary Contact	Insert			GALEOTA, NICHOLAS DIRECTOR OF PHARMACY 7182703115	8/22/2016 1:20 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 1:20 PM
Addresses	Shipping Address	Insert			SUNY Downstate Medical Center at LICH 445 Lenox Road Attn: Pharmacy Box 36 Brooklyn, NY 11203	10/21/2015 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/10/2015 12:02 PM
Contacts	Authorizing Official	Update		Caralis, George P. Interim CEO 7182704293	Jones, Anthony K. Interim CEO 7182704293	8/10/2015 12:02 PM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 12:02 PM
Details	Last Recertification Date	Update		9/11/2013 12:00:00 AM	9/8/2014 12:00:00 AM	9/8/2014 1:31 PM
Contacts	Authorizing Official	Insert			Caralis, George P. Interim CEO 7182704293	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/11/2013 12:00:00 AM	9/11/2013 1:10 PM
Medicaid Billing	NPI: Number	Insert			1639179328	5/22/2012 12:40 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/22/2012 12:40 PM
Details	Last Recertification Date	Insert				10/30/2007 1:50 PM
Details	Grant Number	Insert				10/30/2007 1:50 PM
Details	340B ID	Insert			DSH330350	10/30/2007 1:50 PM
Details	Is Authorizing Official EHB Data	Insert				10/30/2007 1:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/30/2007 1:50 PM
Details	Medicare Provider Number	Insert			330350	10/30/2007 1:50 PM
Details	Entity Name	Insert			UNIVERSITY HOSPITAL OF BROOKLYN	10/30/2007 1:50 PM
Details	Program Code	Insert			DSH	10/30/2007 1:50 PM
Details	Entity Subname	Insert			SUNY DOWNSTATE MEDICAL CENTER	10/30/2007 1:50 PM
Dates	Participating Approval Date	Insert			9/14/2007 12:00:00 AM	10/30/2007 1:50 PM
Details	State	Insert			Active	10/30/2007 1:50 PM
Dates	Registration Date	Insert			9/14/2007 12:00:00 AM	10/30/2007 1:50 PM
Dates	Signed By Date	Insert				10/30/2007 1:50 PM
Dates	Start Date	Insert			12/1/1992 12:00:00 AM	10/30/2007 1:50 PM
Terminations	Termination Comments	Insert				10/30/2007 1:50 PM
Terminations	Termination Date	Insert				10/30/2007 1:50 PM
Terminations	Termination Effective Date	Insert				10/30/2007 1:50 PM
Terminations	Termination Reason	Insert				10/30/2007 1:50 PM
Details	Comments Public	Insert			9/14/07 ADMIN CORRECTION (REVERSED ENT NAME AND SUB-DIV NAME)	10/30/2007 1:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/14/2007 3:34 PM
Medicaid Billing	Medicaid: Number	Insert			00243590	9/14/2007 3:34 PM
Medicaid Billing	Medicaid: State	Insert			NY	9/14/2007 3:34 PM