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CORAM HEALTHCARE CORPORATION OF GREATER
DSH330188 Mount St. Mary's Hospital and Health Center
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Covered Entity Details
Entity Name
Mount St. Mary's Hospital and Health Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330188
Entity Address
5300 MILITARY ROAD
LEWISTON, NY 14092
Medicare Provider Number
330188
Participating Start Date
1/1/2014
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
CORAM HEALTHCARE CORPORATION OF GREATER
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
375 NORTH FRENCH RD
SUITE 108
AMHERST, NY 14228
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
GARY TUCKER, PRESIDENT/CEO
(716) 298-2004
Contract Pharmacy Representative
CVS Health/Specialty
Jen Jagodzinski, Senior Director, Specialty Product Development
(847) 559-4702
Signed By Date
4/17/2017
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