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ISLAND CARE 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
ISLAND CARE PHARMACY INC
Pharmacy Address
PARAMOUNT SPECIALTY PHARMACY
150 NEW SCOTLAND AVE
ALBANY, NY 12208-3423
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
1/29/2021
Pharmacy closed
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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