Contract Pharmacy Details

MAGELLAN RX PHARMACY, LLC.
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

MAGELLAN RX PHARMACY, LLC.

Pharmacy Address

31-75 23RD STREET
SUITE 410
ASTORIA, NY 11106

Pharmacy Comments

Contract Details

Approval Date

7/15/2016

Contract Begin Date

10/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/15/2016
Agreement registered in error

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

Eddie Wong, Pharmacist
(407) 858-6206

Signed By Date

7/15/2016