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31ST & 3RD PHARMACY INC
DSH330236 NewYork-Presbyterian/Brooklyn Methodist
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Covered Entity Details
Entity Name
NewYork-Presbyterian/Brooklyn Methodist
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330236
Entity Address
506 SIXTH STREET
BROOKLYN, NY 11215
Medicare Provider Number
330236
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2022
Entity Termination Date
10/1/2022
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
7/16/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
1/1/2019
Contract Comments
Contract Termination Date
Termination Reason
6/30/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael P. Fagan, Senior VP of Finance
(718) 780-3031
Contract Pharmacy Representative
Paramount SPecialty
Al DosSantos, Founding Principle
(631) 815-5776
Signed By Date
7/16/2018
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