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BROADWAY PENORA, INC.
DSH330005 KALEIDA HEALTH
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Covered Entity Details
Entity Name
KALEIDA HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330005
Entity Address
100 High Street
BUFFALO, NY 14203
Medicare Provider Number
330005
Participating Start Date
4/1/2006
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
BROADWAY PENORA, INC.
Pharmacy Address
DBA: TOPS MARKET #114
5175 BROADWAY
DEPEW, NY 14043
Pharmacy Comments
Contract Details
Approval Date
4/8/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jonathan Thomas Swiatkowski, EVP, Chief Financial Officer
(716) 859-8836
Contract Pharmacy Representative
Tops Markets
Matthew Hamed, Director of Pharmacy
(716) 635-5274
Signed By Date
4/8/2019
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