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ST LUKES ROOSEVELT HOSPITAL CENTER
DSH330169 MOUNT SINAI BETH ISRAEL
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Covered Entity Details
Entity Name
MOUNT SINAI BETH ISRAEL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330169
Entity Address
FIRST AVENUE AT 16TH STREET
NEW YORK, NY 10003
Medicare Provider Number
330169
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
ST LUKES ROOSEVELT HOSPITAL CENTER
Pharmacy Address
C/O OUTPATIENT PHARMACY
1000 10TH AVE FL 2
NEW YORK, NY 10019
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/27/2020
Ownership change
Contacts
Covered Entity Signing Official
Michael Bruno, Sr. Vice President
(212) 523-7140
Contract Pharmacy Representative
MAISOUN SIOUFI, DIRECTOR, OUTPATIENT PHARMACY
(212) 636-3600
Signed By Date
10/14/2015
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