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FOZI-INC SAN JUAN PHARMACY
DSH330240 HARLEM HOSPITAL CENTER (NYCHHC)
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Covered Entity Details
Entity Name
HARLEM HOSPITAL CENTER (NYCHHC)
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330240
Entity Address
506 LENOX AVENUE
NEW YORK, NY 10037
Medicare Provider Number
330240
Participating Start Date
12/1/1992
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
FOZI-INC SAN JUAN PHARMACY
Pharmacy Address
960 AMSTERDAM AVE
CORN 107 ST
NEW YORK, NY 10025
Pharmacy Comments
Contract Details
Approval Date
7/17/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Antonio Martin, Ececutive Vice President & Chief Operating Officier
(212) 788-3479
Contract Pharmacy Representative
Razi Siddiqui, Owner
(212) 222-4650
Signed By Date
7/17/2014
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