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LIBERTY ROCK PHARMACY INC.
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
LIBERTY ROCK PHARMACY INC.
Pharmacy Address
DBA: SUREDRUGS PHARMACY
118-06 101ST AVE
SOUTH RICHMOND HILL, NY 11419-1230
Pharmacy Comments
Contract Details
Approval Date
10/2/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Albertson, Vice President
(212) 748-2256
Contract Pharmacy Representative
Liberty Rock Pharmacy Inc
Aparna Rathod, Supervising Pharmacist
(718) 880-2500
Signed By Date
10/2/2019
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