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31ST & 3RD PHARMACY INC
DSH330188R 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
MSM HEALTH CENTER LOCKPORT - HEALTH CENTER
Type
Disproportionate Share Hospital
340B ID
DSH330188R
Entity Address
6000 BROCKTON DR
STE 106
LOCKPORT, NY 14094-9273
Medicare Provider Number
330188
Outpatient Facility Provider Number
Participating Start Date
10/1/2019
Last Recertification Date
8/29/2023
Entity Termination Date
4/1/2024
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
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
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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