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MEDLY PHARMACY INC.
DSH330233 BROOKDALE HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BROOKDALE HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330233
Entity Address
ONE BROOKDALE PLAZA
BROOKLYN, NY 11212
Medicare Provider Number
330233
Participating Start Date
10/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
MEDLY PHARMACY INC.
Pharmacy Address
DBA MEDLY PHARMACY
31 DEBEVOISE ST
BROOKLYN, NY 11206-4196
Pharmacy Comments
Contract Details
Approval Date
4/13/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diana Sullivan, VP
(718) 240-7449
Contract Pharmacy Representative
Medly Pharmacy
Jitendra Patel, Pharmacy Director
(718) 782-7539
Signed By Date
4/13/2022
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