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PINE PHARMACY OF NIAGARA FALLS, LLC
DSH330065 NIAGARA FALLS MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NIAGARA FALLS MEMORIAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330065
Entity Address
621-10TH STREET
NIAGARA FALLS, NY 14302
Medicare Provider Number
330065
Participating Start Date
10/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PINE PHARMACY OF NIAGARA FALLS, LLC
Pharmacy Address
1806 PINE AVENUE
NIAGARA FALLS, NY 14301
Pharmacy Comments
Contract Details
Approval Date
8/3/2009
Contract Begin Date
8/3/2009
Carve-In Effective Date
Contract Comments
8/10/2010 - HAD PREVIOUS CP RELATIONSHIP BETWEEN 2/22/2007 AND 4/24/2007.
Contract Termination Date
Termination Reason
9/15/2017
Ownership change
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
7/30/2009
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