Contract Pharmacy Details

MY CHS RX INC.
DSH330286 GOOD SAMARITAN HOSPITAL

Covered Entity Details

Entity Name

GOOD SAMARITAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330286

Entity Address

1000 MONTAUK HIGHWAY
WEST ISLIP, NY 11795

Medicare Provider Number

330286

Participating Start Date

11/7/2022

Last Recertification Date

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

MY CHS RX INC.

Pharmacy Address

4295 HEMPSTEAD TPKE STE 14
BETHPAGE, NY 11714

Pharmacy Comments

Contract Details

Approval Date

11/7/2022

Contract Begin Date

1/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/4/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Stephen Trapani, SVP Finance
(631) 376-3583

Contract Pharmacy Representative

chs
nasser saad, avp pharmacy
(516) 705-2910

Signed By Date

10/11/2022