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CVS ALBANY, L.L.C.
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
CVS ALBANY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 02436
1346 PENNSYLVANIA AVENUE
BROOKLYN, NY 11239
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ramon Rodriguez, President and CEO
(718) 963-7101
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/11/2017
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