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31ST & 3RD PHARMACY INC
DSH330078Q SISTERS OF CHARITY HOSPITAL
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Covered Entity Details
Entity Name
SISTERS OF CHARITY HOSPITAL
Subdivision Name
St. Joseph Campus - Physical Therapy
Type
Disproportionate Share Hospital
340B ID
DSH330078Q
Entity Address
2605 Harlem Road
Cheektowaga, NY 14225
Medicare Provider Number
330078
Outpatient Facility Provider Number
330078
Participating Start Date
1/1/2014
Last Recertification Date
8/29/2023
Entity Termination Date
4/1/2024
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
Contract Termination Date
Termination Reason
4/1/2024
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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