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31ST & 3RD PHARMACY INC
DSH330188J Mount St. Mary's Hospital and Health Center
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Covered Entity Details
Entity Name
Mount St. Mary's Hospital and Health Center
Subdivision Name
Mount St. Mary's Surgical Services
Type
Disproportionate Share Hospital
340B ID
DSH330188J
Entity Address
5320 Military Road
Suite 107
Lewiston, NY 14092-1997
Medicare Provider Number
330188
Outpatient Facility Provider Number
Participating Start Date
10/1/2016
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
31ST & 3RD PHARMACY INC
Pharmacy Address
D/B/A AVITA PHARMACY 1063
1860 WALT WHITMAN RD STE 700
MELVILLE, NY 11747
Pharmacy Comments
Contract Details
Approval Date
6/27/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
7/1/2018
Contract Comments
Contacts
Covered Entity Signing Official
Michael Osborne, Vice President, Finance
(716) 828-2011
Contract Pharmacy Representative
Paramount Pharmacy
John F. Civitello, 340B Program Director
(631) 815-5778
Signed By Date
6/27/2018
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