Contract Pharmacy Details

CVS ALBANY, L.L.C.
DSH330194 MAIMONIDES MEDICAL CENTER

Covered Entity Details

Entity Name

MAIMONIDES MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330194

Entity Address

4802 TENTH AVE.
BROOKLYN, NY 11219

Medicare Provider Number

330194

Participating Start Date

10/1/2004

Last Recertification Date

8/30/2024

Pharmacy Details

Pharmacy Name

CVS ALBANY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 02699
411 DITMAS AVENUE
BROOKLYN, NY 11218

Pharmacy Comments

Contract Details

Approval Date

7/14/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/1/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

PAMELA BRIER, CEO
(718) 283-6009

Contract Pharmacy Representative

CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241

Signed By Date

7/14/2014

340B Drug Pricing Program Database