Covered Entity Details

DSH330221G WYCKOFF HEIGHTS MEDICAL CENTER (Active) - information as of 5/29/2025 2:00:18 AM

Main Details

Name

WYCKOFF HEIGHTS MEDICAL CENTER

Subdivision Name

WYCKOFF DOCTORS - GENERAL MEDICINE

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330221G

Medicare Provider Number

330221

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/4/2023

Participating Start Date

7/1/2023

Participating Approval Date

4/19/2023

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Wyckoff Heights Medical Center
Vali Gache, Chief Executive Officer
(718) 204-1791

Primary Contact

Wyckoff Heights Medical Center
Joseph S Rumore, Director of Pharmacy
(718) 963-7547 Ext: 7141

Addresses

Street Address

1419 Myrtle Ave
Brooklyn, NY 11237

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

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	00243825	1700886322

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330221B	Child	DSH	WYCKOFF HEIGHTS MEDICAL CENTER	WOMEN'S HEALTH CENTER	110 WYCKOFF AVE	BROOKLYN	NY	Active
DSH330221D	Child	DSH	WYCKOFF HEIGHTS MEDICAL CENTER	LAMARCA FAMILY HEALTH CENTER	179 JAMAICA AVE	BROOKLYN	NY	Terminated
DSH330221E	Child	DSH	WYCKOFF HEIGHTS MEDICAL CENTER	PEDIATRIC CENTER	1411 MYRTLE AVENUE	BROOKLYN	NY	Active
DSH330221F	Child	DSH	WYCKOFF HEIGHTS MEDICAL CENTER	EXTENSION CLINIC	1610 DEKALB AVENUE	BROOKLYN	NY	Active
DSH330221G	Child	DSH	WYCKOFF HEIGHTS MEDICAL CENTER	WYCKOFF DOCTORS - GENERAL MEDICINE	1419 Myrtle Ave	Brooklyn	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Rodriguez, Ramon President and CEO Wyckoff Heights Medical Center 7189637101	Gache, Vali Chief Executive Officer Wyckoff Heights Medical Center 7182041791	1/27/2025 1:40 PM
Details	Last Recertification Date	Update	Recertification	8/14/2023 1:07:53 PM	8/16/2024 3:32:26 PM	8/16/2024 3:32 PM
Details	Last Recertification Date	Update	Recertification		8/14/2023 1:07:53 PM	8/14/2023 1:07 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/5/2023 2:12 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		00243825	6/5/2023 2:12 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	6/5/2023 2:12 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700886322	6/5/2023 2:12 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NY	6/5/2023 2:12 PM
Contacts	Signed By	Insert	New Registration		Rodriguez, Ramon President and CEO Wyckoff Heights Medical Center 7189637101	4/19/2023 9:01 AM
Details	340B ID	Update	New Registration		DSH330221G	4/19/2023 9:01 AM
Details	Entity Subname	Update	New Registration	WYCKOFF DOCTORS	WYCKOFF DOCTORS - GENERAL MEDICINE	4/19/2023 9:01 AM
Dates	Participating Approval Date	Update	New Registration		4/19/2023 9:01:58 AM	4/19/2023 9:01 AM
Details	State	Update	New Registration	Pending	Approved	4/19/2023 9:01 AM
Dates	Signed By Date	Update	New Registration		4/4/2023 2:37:03 PM	4/19/2023 9:01 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	4/19/2023 9:01 AM
Addresses	Main Address	Insert	New Registration		1419 Myrtle Ave Brooklyn, NY 11237	4/4/2023 11:50 AM
Contacts	Primary Contact	Insert	New Registration		Rumore, Joseph S Director of Pharmacy Wyckoff Heights Medical Center 7189637547-7141	4/4/2023 11:50 AM
Contacts	Authorizing Official	Insert	New Registration		Rodriguez, Ramon President and CEO Wyckoff Heights Medical Center 7189637101	4/4/2023 11:50 AM
Details	Assistance Received From Date	Insert	New Registration			4/4/2023 11:50 AM
Details	Assistance Received To Date	Insert	New Registration			4/4/2023 11:50 AM
Details	Last Recertification Date	Insert	New Registration			4/4/2023 11:50 AM
Details	Grant Number	Insert	New Registration			4/4/2023 11:50 AM
Details	340B ID	Insert	New Registration			4/4/2023 11:50 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/4/2023 11:50 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/4/2023 11:50 AM
Details	Medicare Provider Number	Insert	New Registration		330221	4/4/2023 11:50 AM
Details	Entity Name	Insert	New Registration		WYCKOFF HEIGHTS MEDICAL CENTER	4/4/2023 11:50 AM
Details	NOFO Number	Insert	New Registration			4/4/2023 11:50 AM
Details	Program Code	Insert	New Registration		DSH	4/4/2023 11:50 AM
Details	Entity Subname	Insert	New Registration		WYCKOFF DOCTORS	4/4/2023 11:50 AM
Dates	Participating Approval Date	Insert	New Registration			4/4/2023 11:50 AM
Details	State	Insert	New Registration		Pending	4/4/2023 11:50 AM
Dates	Registration Date	Insert	New Registration		4/4/2023 11:50:37 AM	4/4/2023 11:50 AM
Dates	Signed By Date	Insert	New Registration			4/4/2023 11:50 AM
Dates	Start Date	Insert	New Registration			4/4/2023 11:50 AM
Terminations	Termination Comments	Insert	New Registration			4/4/2023 11:50 AM
Terminations	Termination Date	Insert	New Registration			4/4/2023 11:50 AM
Terminations	Termination Effective Date	Insert	New Registration			4/4/2023 11:50 AM
Terminations	Termination Reason	Insert	New Registration			4/4/2023 11:50 AM