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KINGS PARK SLOPE INC
DSH330046B MOUNT SINAI WEST
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Covered Entity Details
Entity Name
MOUNT SINAI WEST
Subdivision Name
ST LUKE'S HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH330046B
Entity Address
1111 AMSTERDAM AVENUE
NEW YORK, NY 10025
Medicare Provider Number
330046
Outpatient Facility Provider Number
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
KINGS PARK SLOPE INC
Pharmacy Address
D/B/A KINGS SUPER PHARMACY
357 FLATBUSH AVE
BROOKLYN, NY 11238
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
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Bruno, Sr. Vice President
(212) 523-7140
Contract Pharmacy Representative
Promesa, Inc.
Dimitry Vagman, Supervising Pharmacist
(718) 230-3535
Signed By Date
4/15/2016
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