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QUEENSBRIDGE PLAZA PHARMACY CORP
DSH330221 WYCKOFF HEIGHTS MEDICAL CENTER
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Covered Entity Details
Entity Name
WYCKOFF HEIGHTS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330221
Entity Address
374 STOCKHOLM STREET
BROOKLYN, NY 11237
Medicare Provider Number
330221
Participating Start Date
10/4/2019
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
QUEENSBRIDGE PLAZA PHARMACY CORP
Pharmacy Address
10-37 41ST AVE
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
10/4/2019
Contract Begin Date
10/4/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/12/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ramon Rodriguez, President and CEO
(718) 963-7101
Contract Pharmacy Representative
Wyckoff Heights Medical Center
Joseph S Rumore, Director of Pharmacy
(718) 963-7547 Ext: 7141
Signed By Date
10/4/2019
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