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31ST & 3RD PHARMACY INC
DSH330078AQ SISTERS OF CHARITY HOSPITAL
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Covered Entity Details
Entity Name
SISTERS OF CHARITY HOSPITAL
Subdivision Name
OLV FAMILY CARE CENTER - OLV Family Care
Type
Disproportionate Share Hospital
340B ID
DSH330078AQ
Entity Address
227 RIDGE RD
LACKAWANNA, NY 14218-1156
Medicare Provider Number
330078
Outpatient Facility Provider Number
Participating Start Date
4/1/2021
Last Recertification Date
8/16/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
31ST & 3RD PHARMACY INC
Pharmacy Address
D/B/A AVITA PHARMACY 1063
1860 WALT WHITMAN RD STE 700
MELVILLE, NY 11747
Pharmacy Comments
Contract Details
Approval Date
7/30/2021
Contract Begin Date
8/5/2021
Carve-In Effective Date
10/1/2021
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Osborne, Vice President, Finance
(716) 828-2011
Contract Pharmacy Representative
Paramount Pharmacy
John F. Civitello, 340B Program Director
(631) 815-5778
Signed By Date
7/30/2021
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