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NORTH SHORE UNIVERSITY HOSPITAL
DSH330195BR LONG ISLAND JEWISH MEDICAL CENTER
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Covered Entity Details
Entity Name
LONG ISLAND JEWISH MEDICAL CENTER
Subdivision Name
BACKSTRETCH CLINIC AT BELMONT RACETRACK - Clinic
Type
Disproportionate Share Hospital
340B ID
DSH330195BR
Entity Address
2150 HEMPSTEAD TURNPIKE COTTAGE 58C
BELMONT, NY 11003
Medicare Provider Number
330195
Outpatient Facility Provider Number
Participating Start Date
10/1/2022
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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