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PORT JERVIS PHARMACY LLC
CH020620 Cornerstone Family Healthcare
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Covered Entity Details
Entity Name
Cornerstone Family Healthcare
Subdivision Name
Cornerstone Family Healthcare: The Kaplan Family Pavilion
Type
HRSA-Funded Health Center
340B ID
CH020620
Entity Address
147 Lake St
Newburgh, NY 12550
Grant Number
H80CS00469
Participating Start Date
1/1/1999
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
PORT JERVIS PHARMACY LLC
Pharmacy Address
15 JERSEY AVE STE 2
PORT JERVIS, NY 12771
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Jolly, CEO
(845) 220-3165
Contract Pharmacy Representative
Port Jervis Pharmacy
Janice Vicaretti, Pharmacist
(845) 856-6681
Signed By Date
7/15/2024
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