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58TH STREET PHARMACY, INC.
DSH330046A MOUNT SINAI WEST
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Covered Entity Details
Entity Name
MOUNT SINAI WEST
Subdivision Name
ROOSEVELT HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH330046A
Entity Address
1000 10TH AVENUE
NEW YORK, NY 10019
Medicare Provider Number
330046
Outpatient Facility Provider Number
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
58TH STREET PHARMACY, INC.
Pharmacy Address
DBA TOWN DRUG AND SURGICAL
428 WEST 59TH STREET
NEW YORK, NY 10019
Pharmacy Comments
Contract Details
Approval Date
4/2/2007
Contract Begin Date
4/2/2007
Carve-In Effective Date
Contract Comments
9/24/08-UPDATED ADDRESS (WAS 881 10TH AVE.)
Contract Termination Date
Termination Reason
6/27/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
3/28/2007
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