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STJ RX INC
DSH330397 INTERFAITH MEDICAL CENTER
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Covered Entity Details
Entity Name
INTERFAITH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330397
Entity Address
1545 ATLANTIC AVENUE
BROOKLYN, NY 11213
Medicare Provider Number
330397
Participating Start Date
7/1/2005
Last Recertification Date
9/14/2020
Entity Termination Date
6/1/2021
Pharmacy Details
Pharmacy Name
STJ RX INC
Pharmacy Address
DBA: THRIFTWAY PHARMACY
720 CLASSON AVE
BROOKLYN, NY 11238-4231
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Charles Bove, COO
(718) 613-6465
Contract Pharmacy Representative
STJ Rx
Frank Pipitone, Supervising Pharmacist
(718) 399-1800
Signed By Date
7/15/2016
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