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ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
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
ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Pharmacy Address
ICAHN SCHOOL OF MEDICINE PHARMACY
1468 MADISON AVE
ANNENBERG-MC LEVEL
NEW YORK, NY 10029
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/27/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Michael Bruno, Sr. Vice President
(212) 523-7140
Contract Pharmacy Representative
Ichan School of Medicine Pharmacy
Jose Almonte, Assistant Director of Pharmacy
(212) 241-7720
Signed By Date
4/15/2016
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