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BAISLEY PHARMACY
DSH330231 QUEENS HOSPITAL CENTER (NYCHHC)
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Covered Entity Details
Entity Name
QUEENS HOSPITAL CENTER (NYCHHC)
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330231
Entity Address
82-68 164TH ST.
JAMAICA, NY 11432
Medicare Provider Number
330231
Participating Start Date
12/1/1992
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
BAISLEY PHARMACY
Pharmacy Address
D/B/A COOP PHARMACY
165-70 BAISLEY BLVD
JAMAICA, NY 11434
Pharmacy Comments
Contract Details
Approval Date
4/3/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Albertson, Vice President
(212) 748-2256
Contract Pharmacy Representative
BAISLEY PHARMACY
SAUD ANSARI, PRESIDENT
(718) 528-2246
Signed By Date
4/3/2019
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