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31ST & 3RD PHARMACY INC
DSH330188N 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
Mount St. Mary's Primary Care - Infectious Disease - Infectious Disease
Type
Disproportionate Share Hospital
340B ID
DSH330188N
Entity Address
5290 Military Road
Suite 8 Lower
Lewiston, NY 14092-1997
Medicare Provider Number
330188
Outpatient Facility Provider Number
Participating Start Date
7/1/2019
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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