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E R BLACK PHARMACY
DSH330044 MVHS, Inc. DBA: Wynn Hospital
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Covered Entity Details
Entity Name
MVHS, Inc. DBA: Wynn Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330044
Entity Address
111 Hospital Drive
Utica, NY 13502
Medicare Provider Number
330044
Participating Start Date
7/1/2014
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
E R BLACK PHARMACY
Pharmacy Address
9553 MAIN ST.
HOLLAND PATENT, NY 13354
Pharmacy Comments
Contract Details
Approval Date
4/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Louis Aiello, Sr. VP Finance/ CFO
(315) 917-8213
Contract Pharmacy Representative
Earl Black, Owner
(315) 525-2054
Signed By Date
4/11/2017
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