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STATE UNIVERSITY OF NEW YORK
DSH330350 UNIVERSITY HOSPITAL OF BROOKLYN
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL OF BROOKLYN
Subdivision Name
SUNY DOWNSTATE MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH330350
Entity Address
445 LENOX ROAD
Attn: Pharmacy Box 36
BROOKLYN, NY 11203
Medicare Provider Number
330350
Participating Start Date
12/1/1992
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
STATE UNIVERSITY OF NEW YORK
Pharmacy Address
OUTPATIENT PHARMACY
750 E ADAMS ST LOBBY
SYRACUSE, NY 13210
Pharmacy Comments
Contract Details
Approval Date
4/21/2021
Contract Begin Date
4/22/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Richard Bayard Miller, Chief Financial OIfficer
(718) 270-4901
Contract Pharmacy Representative
SUNY Upstate Medical University Hospital
Eric Balotin, Associate Director of Pharmacy
(315) 464-4215
Signed By Date
4/21/2021
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