Contract Pharmacy Details

CVS ALBANY, L.L.C.
DSH330194 MAIMONIDES MEDICAL CENTER

Covered Entity Details

Entity Name

MAIMONIDES MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330194

Entity Address

4802 TENTH AVE.
BROOKLYN, NY 11219

Medicare Provider Number

330194

Participating Start Date

10/1/2004

Last Recertification Date

8/30/2024

Pharmacy Details

Pharmacy Name

CVS ALBANY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 05134
2014 CROPSEY AVENUE
BROOKLYN, NY 11214

Pharmacy Comments

Contract Details

Approval Date

10/15/2021

Contract Begin Date

1/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/4/2021
Pharmacy closed

Contacts

Covered Entity Signing Official

KENNETH D. GIBBS, CEO
(718) 283-6575

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/15/2021

340B Drug Pricing Program Database