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HEALTHSOURCE PHARMACY II INC
DSH330204 BELLEVUE HOSPITAL CENTER (NYCHHC)
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Covered Entity Details
Entity Name
BELLEVUE HOSPITAL CENTER (NYCHHC)
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330204
Entity Address
462 FIRST AVENUE @ 27TH STREET
D/B/A NYC HEALTH & HOSPITAL CORP
NEW YORK, NY 10016
Medicare Provider Number
330204
Participating Start Date
8/1/1993
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
HEALTHSOURCE PHARMACY II INC
Pharmacy Address
120 E 34TH ST
NEW YORK, NY 10016-4609
Pharmacy Comments
Contract Details
Approval Date
1/3/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Antonio Martin, Ececutive Vice President & Chief Operating Officier
(212) 788-3479
Contract Pharmacy Representative
Boris Nayazov, Pharmacist
(212) 481-6600
Signed By Date
1/3/2014
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