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ST LUKES ROOSEVELT HOSPITAL CENTER
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
ST LUKES ROOSEVELT HOSPITAL CENTER
Pharmacy Address
C/O OUTPATIENT PHARMACY
1000 10TH AVE FL 2
NEW YORK, NY 10019
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/27/2020
Ownership change
Contacts
Covered Entity Signing Official
KENNETH DAVIS, CEO
(212) 659-8888
Contract Pharmacy Representative
MAISOUN SIOUFI, DIRECTOR, OUTPATIENT PHARMACY
(212) 636-3600
Signed By Date
10/14/2015
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