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NORTH SHORE UNIVERSITY HOSPITAL
DSH330195AV LONG ISLAND JEWISH MEDICAL CENTER
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Covered Entity Details
Entity Name
LONG ISLAND JEWISH MEDICAL CENTER
Subdivision Name
SBHC - August Martin - School-based Health Center
Type
Disproportionate Share Hospital
340B ID
DSH330195AV
Entity Address
156-10 Baisley Blvd
Room 116
Jamaica, NY 11434
Medicare Provider Number
330195
Outpatient Facility Provider Number
Participating Start Date
1/1/2021
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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