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PORT EWEN RX INC.
CH02371C INSTITUTE FOR FAMILY HEALTH, THE
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Covered Entity Details
Entity Name
INSTITUTE FOR FAMILY HEALTH, THE
Subdivision Name
SIDNEY HILLMAN and PHILLIPS FAMILY PRACTICE
Type
HRSA-Funded Health Center
340B ID
CH02371C
Entity Address
16 EAST 16TH STREET FL 3RD FLOOR
NEW YORK, NY 10003-3105
Grant Number
H80CS00768
Participating Start Date
1/1/2002
Last Recertification Date
2/15/2017
Entity Termination Date
1/1/2018
Pharmacy Details
Pharmacy Name
PORT EWEN RX INC.
Pharmacy Address
D/B/A PORT EWEN PHARMACY
177 BROADWAY
PORT EWEN, NY 12466
Pharmacy Comments
Contract Details
Approval Date
4/4/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nicole Nurse, Sr Vice President for Clinical Affairs
(212) 633-0800 Ext: 1241
Contract Pharmacy Representative
Gold Street Pharma Inc.
Ravi K. Chenna, President
(646) 425-4405
Signed By Date
4/4/2017
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