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31ST & 3RD PHARMACY INC
DSH330188F Mount St. Mary's Hospital and Health Center
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Covered Entity Details
Entity Name
Mount St. Mary's Hospital and Health Center
Subdivision Name
Clinic for Complete Senior Care Center
Type
Disproportionate Share Hospital
340B ID
DSH330188F
Entity Address
1302 Main Street
Niagara Falls, NY 14301
Medicare Provider Number
330188
Outpatient Facility Provider Number
Participating Start Date
1/1/2014
Last Recertification Date
8/30/2024
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
12/23/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
1/1/2020
Contract Comments
Contacts
Covered Entity Signing Official
Michael Osborne, Vice President, Finance
(716) 828-2011
Contract Pharmacy Representative
Paramount SPecialty
Al DosSantos, Founding Principle
(631) 815-5776
Signed By Date
12/23/2019
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