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31ST & 3RD PHARMACY INC
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
31ST & 3RD PHARMACY INC
Pharmacy Address
D/B/A AVITA PHARMACY 1063
1860 WALT WHITMAN RD STE 700
MELVILLE, NY 11747
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
7/1/2018
Contract Comments
Contacts
Covered Entity Signing Official
GARY TUCKER, PRESIDENT/CEO
(716) 298-2004
Contract Pharmacy Representative
Paramount Pharmacy
John F. Civitello, 340B Program Director
(631) 815-5778
Signed By Date
4/17/2017
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