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31ST & 3RD PHARMACY INC
DSH330233 BROOKDALE HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BROOKDALE HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330233
Entity Address
ONE BROOKDALE PLAZA
BROOKLYN, NY 11212
Medicare Provider Number
330233
Participating Start Date
10/1/2004
Last Recertification Date
8/28/2024
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
4/18/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert A. Palermo, CFO
(718) 240-8515
Contract Pharmacy Representative
Paramount Pharmacy
John F. Civitello, 340B Program Director
(631) 815-5778
Signed By Date
4/18/2019
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