Contract Pharmacy Details

DRUG SHOPPE LLC
DSH330046B MOUNT SINAI WEST

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

DRUG SHOPPE LLC

Pharmacy Address

2074 8TH AVENUE
NEW YORK, NY 10026

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

1/9/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Michael Bruno, Sr. Vice President
(212) 523-7140

Contract Pharmacy Representative

ANIEDI ETUK, OWNER
(212) 222-3652

Signed By Date

7/15/2016