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MAGELLAN RX PHARMACY, LLC.
DSH100113 SHANDS TEACHING HOSPITAL AND CLINICS, INC.
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Covered Entity Details
Entity Name
SHANDS TEACHING HOSPITAL AND CLINICS, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100113
Entity Address
1600 SW Archer Road
GAINESVILLE, FL 32610
Medicare Provider Number
100113
Participating Start Date
7/1/1993
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
MAGELLAN RX PHARMACY, LLC.
Pharmacy Address
31-75 23RD STREET
SUITE 410
ASTORIA, NY 11106
Pharmacy Comments
Contract Details
Approval Date
11/28/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Edward Jimenez, CEO
(352) 265-0440
Contract Pharmacy Representative
Jonathan Rich, VP & Associate General Counsel
(860) 507-1944
Signed By Date
10/12/2012
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