Contract Pharmacy Details

PRIME AID PHARMACY INC.
DSH330169 MOUNT SINAI BETH ISRAEL

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

PRIME AID PHARMACY INC.

Pharmacy Address

3915 BERGENLINE AVENUE
UNION CITY, NJ 07087-0899

Pharmacy Comments

Contract Details

Approval Date

7/18/2016

Contract Begin Date

10/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/13/2017
Pharmacy closed

Contacts

Covered Entity Signing Official

Michael Bruno, Sr. Vice President
(212) 523-7140

Contract Pharmacy Representative

Igor Fleyshmakher, President
(800) 731-4553

Signed By Date

7/18/2016