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STOP & SHOP PHARMACY #2505
DSH330246 ST. CHARLES HOSPITAL
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Covered Entity Details
Entity Name
ST. CHARLES HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330246
Entity Address
200 BELLE TERRE ROAD
PORT JEFFERSON, NY 11777
Medicare Provider Number
330246
Participating Start Date
1/1/2011
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
STOP & SHOP PHARMACY #2505
Pharmacy Address
999 MONTAUK HIGHWAY
SHIRLEY, NY 11967
Pharmacy Comments
Contract Details
Approval Date
7/12/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ronald Weingartner, VP
(631) 474-6600
Contract Pharmacy Representative
st charles
Ronald Weingartner, VP
(631) 474-6600
Signed By Date
7/12/2022
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