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WYCKOFF PHARMACY INC.
DSH330396 WOODHULL HOSPITAL CENTER
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Covered Entity Details
Entity Name
WOODHULL HOSPITAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330396
Entity Address
760 BROADWAY
MAIN ENTRANCE: 720 FLUSHING AV
BROOKLYN, NY 11206
Medicare Provider Number
330396
Participating Start Date
12/1/1992
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WYCKOFF PHARMACY INC.
Pharmacy Address
5 GRAHAM AVENUE
BROOKLYN, NY 11206-4108
Pharmacy Comments
Contract Details
Approval Date
4/10/2013
Contract Begin Date
4/10/2013
Carve-In Effective Date
Contract Comments
04/10/2013 - Public health emergency declared in NY effective 10/27/2012
Contract Termination Date
Termination Reason
7/12/2018
Ownership change
Contacts
Covered Entity Signing Official
Antonio Martin, Ececutive Vice President & Chief Operating Officier
(212) 788-3479
Contract Pharmacy Representative
Wyckoff Pharmacy
Mohammad N. Rana, Owner
(718) 381-6200
Signed By Date
4/10/2013
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