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WESTSIDE FAMILY PHARMACY LLC
DSH330241 UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330241
Entity Address
750 East Adams Street
Syracuse, NY 13210
Medicare Provider Number
330241
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WESTSIDE FAMILY PHARMACY LLC
Pharmacy Address
216 SEYMOUR ST
SYRACUSE, NY 13204-3208
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stuart M. Wright, Chief Financial Officer
(315) 464-5179
Contract Pharmacy Representative
Upstate Family Drugs
Mallika Kopalle, Owner
(732) 678-8459
Signed By Date
1/14/2022
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