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WALGREEN EASTERN CO., INC.
DSH330028 RICHMOND UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
RICHMOND UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330028
Entity Address
355 BARD AVENUE
STATEN ISLAND, NY 10310
Medicare Provider Number
330028
Participating Start Date
11/17/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS #02257
1973 FOREST AVENUE
STATEN ISLAND, NY 10303-2104
Pharmacy Comments
Contract Details
Approval Date
12/16/2011
Contract Begin Date
12/16/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
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