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PROCARE PHARMACY, L.L.C.
DSH330160 STATEN ISLAND UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
STATEN ISLAND UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330160
Entity Address
475 SEAVIEW AVE.
STATEN ISLAND, NY 10305
Medicare Provider Number
330160
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
1/21/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brahim Ardolic, Executive Director
(718) 226-9761
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/21/2021
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