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161 ST PHARMA INC
DSH330009 BronxCare Health System
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Covered Entity Details
Entity Name
BronxCare Health System
Subdivision Name
Fulton Division
Type
Disproportionate Share Hospital
340B ID
DSH330009
Entity Address
1276 FULTON AVE.
BRONX, NY 10456
Medicare Provider Number
330009
Participating Start Date
7/1/1993
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
161 ST PHARMA INC
Pharmacy Address
DBA-161 ST PHARMACY & SURGICAL SUPPLIES
275 E 161ST ST
BRONX, NY 10451-3504
Pharmacy Comments
Contract Details
Approval Date
10/8/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
VICTOR DEMARCO, CFO
(718) 901-8600
Contract Pharmacy Representative
Ravi Rx
Ravi Annamaneni, Pharmacy Owner
(848) 218-3530
Signed By Date
10/8/2018
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