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31ST & 3RD PHARMACY INC
DSH330055A NEWYORK-PRESBYTERIAN / QUEENS
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Covered Entity Details
Entity Name
NEWYORK-PRESBYTERIAN / QUEENS
Subdivision Name
NYP/Queens Center For Developmental Disability and NeuroScience Center
Type
Disproportionate Share Hospital
340B ID
DSH330055A
Entity Address
59-16 174th Street
Flushing, NY 11365
Medicare Provider Number
330055
Outpatient Facility Provider Number
330055
Participating Start Date
1/1/2014
Last Recertification Date
8/23/2024
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
4/1/2019
Contract Comments
Contract Termination Date
Termination Reason
2/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Ward, Senior VP FOR FINANCE
(718) 670-1476
Contract Pharmacy Representative
Paramount SPecialty
Al DosSantos, Founding Principle
(631) 815-5776
Signed By Date
1/15/2019
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