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BROADWAY PENORA, INC.
DSH330078 SISTERS OF CHARITY HOSPITAL
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Covered Entity Details
Entity Name
SISTERS OF CHARITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330078
Entity Address
2157 MAIN STREET
BUFFALO, NY 14214
Medicare Provider Number
330078
Participating Start Date
1/1/2014
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
BROADWAY PENORA, INC.
Pharmacy Address
DBA: TOPS MARKET #114
5175 BROADWAY
DEPEW, NY 14043
Pharmacy Comments
Contract Details
Approval Date
8/20/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Ownership change
Contacts
Covered Entity Signing Official
James A. Dunlop Jr., CFO
(716) 862-2431
Contract Pharmacy Representative
John Kirk, Third Party Coordinator
(716) 635-5277
Signed By Date
8/20/2014
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