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WALGREEN EASTERN CO. INC.
DSH330104 MONTEFIORE NYACK HOSPITAL
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Covered Entity Details
Entity Name
MONTEFIORE NYACK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330104
Entity Address
160 NORTH MIDLAND AVENUE
NYACK, NY 10960
Medicare Provider Number
330104
Participating Start Date
4/1/2006
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO. INC.
Pharmacy Address
WALGREENS #16064
81 ROUTE 303
TAPPAN, NY 10983
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John S. Burke, CFO
(845) 348-2107
Contract Pharmacy Representative
Walgreen Co.
Enrique Anza, Sr. Analyst, 340B Client Relationship
(847) 964-6160
Signed By Date
10/11/2021
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