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PRIME THERAPEUTICS PHARMACY LLC
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
PRIME THERAPEUTICS PHARMACY LLC
Pharmacy Address
6870 SHADOWRIDGE DR STE 111
ORLANDO, FL 32812
Pharmacy Comments
Contract Details
Approval Date
7/18/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
KENNETH DAVIS, CEO
(212) 659-8888
Contract Pharmacy Representative
Eddie Wong, Pharmacist
(407) 858-6206
Signed By Date
7/18/2016
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