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BROOKDALERX, INC.
DSH330233B BROOKDALE HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BROOKDALE HOSPITAL MEDICAL CENTER
Subdivision Name
Brookdale Family Care Center - Pennsylvania Ave Clinic
Type
Disproportionate Share Hospital
340B ID
DSH330233B
Entity Address
1110 Pennsylvania Avenue
Brooklyn, NY 11212
Medicare Provider Number
330233
Outpatient Facility Provider Number
Participating Start Date
4/1/2014
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
BROOKDALERX, INC.
Pharmacy Address
1275 LINDEN BLVD
ATTN: SUPERVISING PHARMACIST
BROOKLYN, NY 11212
Pharmacy Comments
Contract Details
Approval Date
3/31/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
7/1/2017
Contract Comments
Contacts
Covered Entity Signing Official
James Porter, CFO
(718) 240-5773
Contract Pharmacy Representative
Brookdale Hospital
Johnny Ha, Director of Pharmacy
(718) 240-5994
Signed By Date
3/31/2017
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