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31ST & 3RD PHARMACY INC
DSH330236V NewYork-Presbyterian/Brooklyn Methodist
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Covered Entity Details
Entity Name
NewYork-Presbyterian/Brooklyn Methodist
Subdivision Name
Ambulatory Infusion Center
Type
Disproportionate Share Hospital
340B ID
DSH330236V
Entity Address
343 4th Avenue
Brooklyn, NY 11215-9008
Medicare Provider Number
330236
Outpatient Facility Provider Number
Participating Start Date
1/1/2016
Last Recertification Date
9/11/2020
Entity Termination Date
10/1/2021
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
10/1/2021
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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