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ELLAHI DRUGS CORP
DSH330221 WYCKOFF HEIGHTS MEDICAL CENTER
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Covered Entity Details
Entity Name
WYCKOFF HEIGHTS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330221
Entity Address
374 STOCKHOLM STREET
BROOKLYN, NY 11237
Medicare Provider Number
330221
Participating Start Date
10/4/2019
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
ELLAHI DRUGS CORP
Pharmacy Address
DBA:SHAWN PHARMACY
321 WYCKOFF AVE
RIDGEWOOD, NY 11385
Pharmacy Comments
Contract Details
Approval Date
7/25/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/30/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ramon Rodriguez, President and CEO
(718) 963-7101
Contract Pharmacy Representative
Asif Noor, PHARMACIST
(347) 881-7997
Signed By Date
7/25/2014
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