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WALGREEN EASTERN CO., INC.
DSH330160 STATEN ISLAND UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
STATEN ISLAND UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330160
Entity Address
475 SEAVIEW AVE.
STATEN ISLAND, NY 10305
Medicare Provider Number
330160
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS
655 ROSSVILLE AVE
STATEN ISLAND, NY 10309
Pharmacy Comments
Contract Details
Approval Date
7/20/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/22/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brahim Ardolic, Executive Director
(718) 226-9761
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/20/2021
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