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LONG ISLAND JEWISH MEDICAL CENTER AT HOM
DSH330160G STATEN ISLAND UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
STATEN ISLAND UNIVERSITY HOSPITAL
Subdivision Name
Staten Island University Hospital - Alcohol Clinic
Type
Disproportionate Share Hospital
340B ID
DSH330160G
Entity Address
450 Seaview Avenue
Staten Island, NY 10305
Medicare Provider Number
330160
Outpatient Facility Provider Number
Participating Start Date
5/2/2013
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
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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