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ELLIS NOTT STREET PHARMACY
DSH330153 Ellis Hospital
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Covered Entity Details
Entity Name
Ellis Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330153
Entity Address
1101 Nott Street
Schenectady, NY 12308
Medicare Provider Number
330153
Participating Start Date
7/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
ELLIS NOTT STREET PHARMACY
Pharmacy Address
DBA: NOTT STREET PHARMACY
1101 NOTT ST
SCHENECTADY, NY 12308-2425
Pharmacy Comments
Contract Details
Approval Date
7/9/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marc Mesick, CFO & VP of Finance
(518) 243-4144
Contract Pharmacy Representative
ELLIS HOSPITAL
Nicole Jaeger, Main 340B Contact
(518) 612-8833
Signed By Date
7/9/2017
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