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31ST & 3RD PHARMACY INC
DSH330078AE SISTERS OF CHARITY HOSPITAL
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Covered Entity Details
Entity Name
SISTERS OF CHARITY HOSPITAL
Subdivision Name
CHS Partners in Rehab
Type
Disproportionate Share Hospital
340B ID
DSH330078AE
Entity Address
6199 Transit Road
Depew, NY 14043
Medicare Provider Number
330078
Outpatient Facility Provider Number
330078
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2018
Entity Termination Date
10/1/2019
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
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
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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