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MADISON AVENUE PHARMACY INC.
DSH330024 THE MOUNT SINAI HOSPITAL
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Covered Entity Details
Entity Name
THE MOUNT SINAI HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330024
Entity Address
ONE GUSTAVE L. LEVY PLACE
NEW YORK, NY 10029
Medicare Provider Number
330024
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
MADISON AVENUE PHARMACY INC.
Pharmacy Address
1407 MADISON AVE
NEW YORK, NY 10029-6930
Pharmacy Comments
Contract Details
Approval Date
10/5/2012
Contract Begin Date
10/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Pastier, Senior VP/CFO - The Mount Sinai Hospital
(212) 731-3149
Contract Pharmacy Representative
Richard Schirripa, Owner
(845) 222-4056
Signed By Date
9/13/2012
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