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SOUTH BROADWAY PHARMACY INC.
DSH330006 ST. JOSEPHS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. JOSEPHS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330006
Entity Address
127 South Broadway
YONKERS, NY 10701
Medicare Provider Number
330006
Participating Start Date
7/1/2022
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SOUTH BROADWAY PHARMACY INC.
Pharmacy Address
314 S BROADWAY
YONKERS, NY 10705-2049
Pharmacy Comments
Contract Details
Approval Date
10/4/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MICHAEL J SPICER, CEO
(914) 378-7485
Contract Pharmacy Representative
South Broadway Pharmacy inc
Tarek Saleh, Owner
(914) 965-1000
Signed By Date
10/4/2022
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