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NYC DRUG STORE INC
DSH330231 QUEENS HOSPITAL CENTER (NYCHHC)
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Covered Entity Details
Entity Name
QUEENS HOSPITAL CENTER (NYCHHC)
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330231
Entity Address
82-68 164TH ST.
JAMAICA, NY 11432
Medicare Provider Number
330231
Participating Start Date
12/1/1992
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
NYC DRUG STORE INC
Pharmacy Address
DBA-FRANKLIN SQUARE PHARMACY & SURGICAL
925 HEMPSTEAD TPKE
FRANKLIN SQUARE, NY 11010
Pharmacy Comments
Contract Details
Approval Date
4/15/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Albertson, Vice President
(212) 748-2256
Contract Pharmacy Representative
NYC Drug Store
Anil Ravuri, Main Contact
(718) 380-0999
Signed By Date
4/15/2017
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