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VICTORY RX LLC
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
VICTORY RX LLC
Pharmacy Address
RANDALL MANOR PHARMACY AND SURGICAL SUPP
395 FOREST AVE
STATEN ISLAND, NY 10301-2622
Pharmacy Comments
Contract Details
Approval Date
10/23/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph Saporito, CFO
(718) 818-3295
Contract Pharmacy Representative
Nick Amaxas, Owner
(718) 720-2324
Signed By Date
10/23/2015
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