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ACARIAHEALTH PHARMACY #12, 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
ACARIAHEALTH PHARMACY #12, INC.
Pharmacy Address
5 SKYLINE DR STE 240
HAWTHORNE, NY 10532-2166
Pharmacy Comments
Contract Details
Approval Date
10/6/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/3/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Bruno, Sr. Vice President
(212) 523-7140
Contract Pharmacy Representative
Acaria Health
Ed Ochoa, Pharmacist-in-charge
(800) 511-5144
Signed By Date
10/6/2015
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