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ACARIAHEALTH PHARMACY #12, INC.
DSH330195 LONG ISLAND JEWISH MEDICAL CENTER
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Covered Entity Details
Entity Name
LONG ISLAND JEWISH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330195
Entity Address
270-05 76TH AVENUE
NEW HYDE PARK, NY 11040
Medicare Provider Number
330195
Participating Start Date
7/1/2007
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ACARIAHEALTH PHARMACY #12, INC.
Pharmacy Address
5 SKYLINE DR STE 240
HAWTHORNE, NY 10532-2166
Pharmacy Comments
Contract Details
Approval Date
10/16/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/8/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Acaria Health
Philip Gofman, Regional VP
(917) 312-5263
Signed By Date
10/16/2020
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