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BISMILLAH 1 CORPORATION
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
BISMILLAH 1 CORPORATION
Pharmacy Address
DBA ELTON PHARMACY
2992 FULTON ST
BROOKLYN, NY 11208
Pharmacy Comments
Contract Details
Approval Date
1/14/2015
Contract Begin Date
4/1/2015
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
Khalid Masood, Owner
(718) 827-8943
Signed By Date
1/14/2015
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