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31ST & 3RD PHARMACY INC
DSH330059 MONTEFIORE MEDICAL CENTER
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Covered Entity Details
Entity Name
MONTEFIORE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330059
Entity Address
111 EAST 210TH STREET
BRONX, NY 10467
Medicare Provider Number
330059
Participating Start Date
4/1/2005
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
31ST & 3RD PHARMACY INC
Pharmacy Address
D/B/A AVITA PHARMACY 1063
1860 WALT WHITMAN RD STE 700
MELVILLE, NY 11747
Pharmacy Comments
Contract Details
Approval Date
5/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Menashy, Vice President of Finance
(917) 280-2722
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
5/14/2023
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