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UMASS MEMORIAL MEDICAL CENTER, INC.
DSH330059 MONTEFIORE MEDICAL CENTER
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Covered Entity Details
Entity Name
MONTEFIORE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330059
Entity Address
111 EAST 210TH STREET
BRONX, NY 10467
Medicare Provider Number
330059
Participating Start Date
4/1/2005
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
UMASS MEMORIAL MEDICAL CENTER, INC.
Pharmacy Address
UMASS MEMORIAL MEDICAL CENTER SPECIALTY
55 LAKE AVE N
ACC BUILDING - 1ST FLOOR - SUITE AC1.033
WORCESTER, MA 01655-0002
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Colleen M. Blye, Executive Vice President-CFO
(718) 920-7602
Contract Pharmacy Representative
UMass Memorial Medical Center
Roland Bercume, Senior Director of Pharmacy
(774) 442-9270
Signed By Date
4/15/2019
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