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TRUE NORTH HEALTH PHARMACY, INC.
DSH330160Y STATEN ISLAND UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
STATEN ISLAND UNIVERSITY HOSPITAL
Subdivision Name
Medical Arts Pavilion - Rehab Services
Type
Disproportionate Share Hospital
340B ID
DSH330160Y
Entity Address
242 Mason Avenue
1st floor
Staten Island, NY 10305
Medicare Provider Number
330160
Outpatient Facility Provider Number
Participating Start Date
1/1/2022
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
TRUE NORTH HEALTH PHARMACY, INC.
Pharmacy Address
DBA: VIVO HEALTH SPECIALTY PHARMACY
225 COMMUNITY DR STE 100
GREAT NECK, NY 11021-5506
Pharmacy Comments
Contract Details
Approval Date
11/20/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
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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