Contract Pharmacy Details

MY CHS RX INC.
DSH330246 ST. CHARLES HOSPITAL

Covered Entity Details

Entity Name

ST. CHARLES HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330246

Entity Address

200 BELLE TERRE ROAD
PORT JEFFERSON, NY 11777

Medicare Provider Number

330246

Participating Start Date

1/1/2011

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

MY CHS RX INC.

Pharmacy Address

4295 HEMPSTEAD TPKE STE 14
BETHPAGE, NY 11714

Pharmacy Comments

Contract Details

Approval Date

1/6/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Ronald Weingartner, VP
(631) 474-6600

Contract Pharmacy Representative

chs
nasser saad, avp pharmacy
(516) 705-2910

Signed By Date

1/6/2020