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31ST & 3RD PHARMACY INC
DSH330236U NewYork-Presbyterian/Brooklyn Methodist
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Covered Entity Details
Entity Name
NewYork-Presbyterian/Brooklyn Methodist
Subdivision Name
OB/GYN Womens Health Clinic
Type
Disproportionate Share Hospital
340B ID
DSH330236U
Entity Address
263 7th Avenue
Suite 3A
Brooklyn, NY 11215
Medicare Provider Number
330236
Outpatient Facility Provider Number
330236
Participating Start Date
10/1/2014
Last Recertification Date
9/7/2022
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
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
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
1/15/2019
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