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SUPREME RX PHARMACY CORP.
DSH330019 NY COMMUNITY HOSPITAL OF BROOKLYN
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Covered Entity Details
Entity Name
NY COMMUNITY HOSPITAL OF BROOKLYN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330019
Entity Address
2525 KINGS HIGHWAY
BROOKLYN, NY 11229
Medicare Provider Number
330019
Participating Start Date
1/1/2019
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SUPREME RX PHARMACY CORP.
Pharmacy Address
3011 AVENUE N
BROOKLYN, NY 11210
Pharmacy Comments
Contract Details
Approval Date
10/18/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/17/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
LEONARDO TAMBURELLO, CFO
(718) 692-5382
Contract Pharmacy Representative
SUPREME RX
Tanya Mizrahi, owner
(718) 677-6600
Signed By Date
10/15/2018
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