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NORTH SHORE UNIVERSITY HOSPITAL
DSH330195J LONG ISLAND JEWISH MEDICAL CENTER
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Covered Entity Details
Entity Name
LONG ISLAND JEWISH MEDICAL CENTER
Subdivision Name
Pediatric & Adolescent Medicine Clinic / Adolescent Medicine
Type
Disproportionate Share Hospital
340B ID
DSH330195J
Entity Address
410 Lakeville Rd
Suite 108
108
New Hyde Park, NY 11040
Medicare Provider Number
330195
Outpatient Facility Provider Number
Participating Start Date
7/1/2015
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
NORTH SHORE UNIVERSITY HOSPITAL
Pharmacy Address
DBA VIVO HEALTH PHARMACY AT MANHASSET
300 COMMUNITY DRIVE
MANHASSET, NY 11030
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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