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LONG ISLAND JEWISH MEDICAL CENTER AT HOM
DSH330043B SOUTH SHORE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SOUTH SHORE UNIVERSITY HOSPITAL
Subdivision Name
Pain Management
Type
Disproportionate Share Hospital
340B ID
DSH330043B
Entity Address
39 Brentwood Road
202
Bay Shore, NY 11706
Medicare Provider Number
330043
Outpatient Facility Provider Number
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
LONG ISLAND JEWISH MEDICAL CENTER AT HOM
Pharmacy Address
VIVO HEALTH PHARMACY AT HOME
225 COMMUNITY DR STE 140
GREAT NECK, NY 11021-5506
Pharmacy Comments
Contract Details
Approval Date
11/20/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
1/1/2024
Contract Comments
Contacts
Covered Entity Signing Official
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Vivo Health
Scott Jacobson, COO
(508) 254-9792
Signed By Date
11/20/2023
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