Contract Pharmacy Details

DRUG SHOPPE LLC
DSH330046C ST LUKE'S ROOSEVELT HOSPITAL CENTER

Covered Entity Details

Entity Name

ST LUKE'S ROOSEVELT HOSPITAL CENTER

Subdivision Name

TRANSPLANT PROGRAM

Type

Disproportionate Share Hospital

340B ID

DSH330046C

Entity Address

2074 Frederick Douglas Boulevard
NEW YORK, NY 10026

Medicare Provider Number

330046

Outpatient Facility Provider Number

Participating Start Date

7/1/2009

Last Recertification Date

9/9/2014

Entity Termination Date

7/1/2015

Pharmacy Details

Pharmacy Name

DRUG SHOPPE LLC

Pharmacy Address

2074 8TH AVENUE
NEW YORK, NY 10026

Pharmacy Comments

Contract Details

Approval Date

3/8/2010

Contract Begin Date

3/8/2010

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2015

Contacts

Covered Entity Signing Official

Contract Pharmacy Representative

ANIEDI ETUK, OWNER
(212) 222-3652

Signed By Date

3/1/2010

340B Drug Pricing Program Database