Contract Pharmacy Details

PRIME THERAPEUTICS PHARMACY LLC
DSH330046 MOUNT SINAI WEST

Covered Entity Details

Entity Name

MOUNT SINAI WEST

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330046

Entity Address

1000 TENTH AVENUE
NEW YORK, NY 10019

Medicare Provider Number

330046

Participating Start Date

7/1/2005

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

PRIME THERAPEUTICS PHARMACY LLC

Pharmacy Address

6870 SHADOWRIDGE DR STE 111
ORLANDO, FL 32812

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

7/15/2016
Agreement registered in error

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

Eddie Wong, Pharmacist
(407) 858-6206

Signed By Date

7/15/2016