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KINGS PARK SLOPE INC
DSH330024A 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
DSH330024A
Entity Address
25-10 30TH AVENUE
LONG ISLAND CITY, NY 11102
Medicare Provider Number
330024
Outpatient Facility Provider Number
Participating Start Date
7/1/2006
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
KINGS PARK SLOPE INC
Pharmacy Address
D/B/A KINGS SUPER PHARMACY
357 FLATBUSH AVE
BROOKLYN, NY 11238
Pharmacy Comments
Contract Details
Approval Date
4/18/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/27/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SALVATORE MORELLO, DIRECTOR OF FINANCE
(718) 267-4203
Contract Pharmacy Representative
Promesa, Inc.
Dimitry Vagman, Supervising Pharmacist
(718) 230-3535
Signed By Date
4/18/2016
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