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EXPRESS SCRIPTS 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
EXPRESS SCRIPTS PHARMACY, INC.
Pharmacy Address
DBA EXPRESS SCRIPTS
255 PHILLIPI ROAD
COLUMBUS, OH 43228
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/18/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Michael Bruno, Sr. Vice President
(212) 523-7140
Contract Pharmacy Representative
Accredo Specialty Pharmacy
Gene McCabe, Lead Director, 340B Client Sales
(615) 943-7500
Signed By Date
7/14/2017
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