Contract Pharmacy Details

LSC MAIL ORDER PHARMACY
DSH310075 MONMOUTH MEDICAL CENTER

Covered Entity Details

Entity Name

MONMOUTH MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH310075

Entity Address

300 SECOND AVENUE
LONG BRANCH, NJ 07740

Medicare Provider Number

310075

Participating Start Date

10/1/2004

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

LSC MAIL ORDER PHARMACY

Pharmacy Address

605 MONTROSE AVE
SOUTH PLAINFIELD, NJ 07080

Pharmacy Comments

Contract Details

Approval Date

10/25/2011

Contract Begin Date

11/1/2011

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/31/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

John Brennan, Executive Director
(973) 926-7850

Contract Pharmacy Representative

Suzanne Sesta, Vice President
(908) 851-7420

Signed By Date

11/1/2011